| NPI | 1073716262 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOEL WAYLON BLACK Owner Physician 360-754-1739 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: WA MD00013879) |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2012-11-20 |