| Name | Value |
|---|---|
| PROVIDER TYPE | Ambulatory Health Care Facilities |
| CLASSIFICATION | Clinic/Center |
| AREA OF SPECIALIZATION | Public Health, State or Local |
| STATUS | Active |
| X12 CODE | 261QP0905X |
| INDIVIDUAL/NON | NON-INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252216 |
| EFFECTIVE DATE/TIME |
|