| NPI | 1992732291 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER RODRIGUEZ Payer Enrollment Specialist 208-642-9376 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 261QM1300X Clinic/Center, Multi-Specialty | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2021-05-14 |