| NPI | 1164058996 |
|---|---|
| Doing Business As | WISTERIA PLACE ASSISTED LIVING |
| Entity Type | Organization |
| Authorized Contact | LEE JOHNSON Treasurer 208-401-1369 |
| Organization Subpart ? | No |
| Primary Taxonomy | 310400000X Assisted Living Facility |
| Enumeration Date | 2020-03-12 |
| Last Update Date | 2020-03-12 |