| NPI | 1972211357 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACEY BLACKWOOD Credentialing Specialist 208-737-6718 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 261QU0200X Clinic/Center, Urgent Care | |
| 363A00000X Physician Assistant | |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2022-11-14 |
| Last Update Date | 2023-07-21 |