| NPI | 1841780475 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DEGOLIA M JOHNSON Owner 208-208-7613 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center Multi-Specialty |
| Additional Taxonomies | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2021-11-06 |