| NPI | 1154709863 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JONATHAN BRUCE PITTARD Owner/Provider 208-320-0258 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: ID SPHY-345) |
| Enumeration Date | 2015-05-13 |
| Last Update Date | 2015-05-26 |