| NPI | 1356853592 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | VIRGINIA E SMITH Credentialing COO Rdinator 888-737-9615 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QM1300X Clinic/Center Multi-Specialty |
| Enumeration Date | 2017-10-27 |
| Last Update Date | 2020-06-22 |