| NPI | 1124303094 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JUSTIN TYRELL HAMMON President 208-528-6010 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QH0100X Clinic/Center, Health Services (Licence: ID CHIA-1341) |
| Additional Taxonomies | 261QH0100X Clinic/Center, Health Services (Licence: ID ACT-251) |
| Enumeration Date | 2011-10-11 |
| Last Update Date | 2016-12-09 |