| NPI | 1790257921 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TERESA L PORTER Credentialing Manager 660-890-8186 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental |
| Enumeration Date | 2018-12-28 |
| Last Update Date | 2018-12-28 |