| NPI | 1891233243 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CONSTANCE JENSEN Owner 360-518-7520 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: WA MA60678986) |
| Enumeration Date | 2017-02-06 |
| Last Update Date | 2017-02-08 |