| NPI | 1669185898 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMANDA COSSEY Credentialing Manager 870-217-2158 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QR1300X Clinic/Center, Rural Health |
| Additional Taxonomies | 207Q00000X Family Medicine |
| Enumeration Date | 2023-01-03 |
| Last Update Date | 2023-12-28 |