| NPI | 1225834567 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ELIZABETH MYERS Contract Credentialing Specialist 866-912-2746 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2025-02-19 |
| Last Update Date | 2025-02-19 |