| NPI | 1487404679 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CICELY MCCOWAN Revenue Cycle Manager 260-458-2641 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| 1223G0001X Dentist, General Practice | |
| Enumeration Date | 2024-03-22 |
| Last Update Date | 2025-09-19 |