| NPI | 1912478819 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KRISTINE VAN KIRK Owner/Provider 307-823-2968 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine |
| Additional Taxonomies | 2083B0002X Preventive Medicine, Obesity Medicine |
| Enumeration Date | 2018-12-17 |
| Last Update Date | 2018-12-20 |