| NPI | 1255950168 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LILLIAN LEE OMALLEY Insurance Contracting Coor 386-236-3225 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 208D00000X General Practice |
| 261QP2300X Clinic/Center, Primary Care | |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2023-07-28 |