| NPI | 1376004663 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TILINA ROBINSON Credentialing Specialist 307-857-9486 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2019-03-28 |