| NPI | 1538405410 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACEY BLACKWOOD Credentialing 208-737-6718 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2012-12-20 |
| Last Update Date | 2021-05-13 |