| NPI | 1992767800 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WAYNE MYRICK Program Manager 208-455-3754 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment (Licence: ID 332B00000X) |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2020-08-22 |