Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2018-08-09
- Last updated
- 2018-08-09
Specialties
Licenses
- License ID
- p5256
Location
- Practice location
- 3250 MIDWAY DR
- City
- AMMON ID
- Postal code
- 834067650
- Phone
- 208-552-7677
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.