| NPI | 1710503099 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMBER L TUELLER Secretary 208-207-2726 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363L00000X Nurse Practitioner | |
| 261QM1300X Clinic/Center Multi-Specialty | |
| Enumeration Date | 2020-06-22 |
| Last Update Date | 2025-06-10 |