| NPI | 1912382227 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BURGUNDY JOHNSON Billing Manager 872-269-3491 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2015-07-28 |
| Last Update Date | 2025-04-10 |