| NPI | 1871909127 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | QUINN JOE SMITH Owner 208-371-2007 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: TX 30205) |
| Enumeration Date | 2014-07-08 |
| Last Update Date | 2014-07-08 |