| NPI | 1235904160 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ALISHA CRISP Credentialing Specialist 315-298-6564 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QC1500X Clinic/Center Community Health |
| Enumeration Date | 2023-11-21 |
| Last Update Date | 2023-11-21 |