| NPI | 1649894262 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AUDRA FICKEN Sr. Rcm Manager 855-408-1143 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder | |
| Enumeration Date | 2020-05-29 |
| Last Update Date | 2026-01-24 |