| NPI | 1972202919 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TERESA L PORTER Credentialing Manager 660-890-8156 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2023-02-28 |
| Last Update Date | 2023-02-28 |