| NPI | 1306048632 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BURGUNDY JOHNSON Credentialing 872-629-3491 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 251S00000X (Licence: IL 30411) |
| Enumeration Date | 2007-05-31 |
| Last Update Date | 2022-06-29 |