| NPI | 1770171811 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | PETER GLANVILLE Owner/Provider 208-699-9626 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2021-10-29 |