| NPI | 1376283614 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANTHONY DAVENPORT Administrator 773-412-4653 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center Multi-Specialty |
| Additional Taxonomies | 261QC1500X Clinic/Center Community Health |
| Enumeration Date | 2022-04-01 |
| Last Update Date | 2022-07-01 |