| NPI | 1114507928 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TERI ROUSE Agent 208-691-4569 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QP3300X Clinic/Center, Pain |
| Enumeration Date | 2021-04-14 |
| Last Update Date | 2025-01-15 |