| NPI | 1790341303 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | FANAE WATSON Owner/Provider 870-280-1037 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care |
| Additional Taxonomies | 207Q00000X Family Medicine |
| Enumeration Date | 2019-05-20 |
| Last Update Date | 2022-10-25 |