| NPI | 1417473851 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BURGUNDY JOHNSON Billing Manager 872-629-3491 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2017-08-17 |
| Last Update Date | 2022-06-27 |