| NPI | 1073188728 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACEY BLACKWOOD Credentialing Specialist 208-737-6718 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 101Y00000X Counselor |
| 103T00000X Psychologist | |
| 104100000X Social Worker | |
| 122300000X Dentist | |
| 1223G0001X Dentist General Practice | |
| 124Q00000X Dental Hygienist | |
| 126800000X Dental Assistant | |
| 207Q00000X Family Medicine | |
| 2084P0800X Psychiatry & Neurology Psychiatry | |
| 363A00000X Physician Assistant | |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2023-06-26 |