NPI age
20 years
Enumerated 2005-08-26
Across 6 active clinic/center providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (ID) | 000010138805 | IDAHO MEDICAID |
| 01 (ID) | 84095 | BLUE CROSS |
| 05 (ID) | 002642800 |
Doing-business-as, former, and alternate names recorded by NPPES.
Single-site organization. Only one practice location on file.
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