| NPI | 1275205809 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LACHELLE GRIFFIN Credentialing Manager 769-208-4437 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty |
| Additional Taxonomies | 2086S0129X |
| Enumeration Date | 2021-10-01 |
| Last Update Date | 2024-10-23 |