| NPI | 1477047926 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MATTHEW L KOOYMAN Owner 208-899-2384 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: ID D-3565) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-3565) |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2018-06-19 |