| NPI | 1689383259 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACEY BLACKWOOD Credentialing Specialist 208-737-6718 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 101YM0800X Counselor, Mental Health | |
| 1041C0700X Social Worker, Clinical | |
| 1223G0001X Dentist, General Practice | |
| 124Q00000X Dental Hygienist | |
| 183500000X Pharmacist | |
| 207Q00000X Family Medicine | |
| 3336C0003X Pharmacy, Community/Retail Pharmacy | |
| 363A00000X Physician Assistant | |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2022-11-22 |
| Last Update Date | 2022-11-22 |