| NPI | 1962990465 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | PHILIP BAQUIE Owner 662-371-1711 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2018-04-30 |
| Last Update Date | 2018-04-30 |