| NPI | 1366811267 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIFFANY GAURON Office Manager 208-376-5433 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: ID C0610) |
| Enumeration Date | 2015-09-21 |
| Last Update Date | 2015-09-21 |