Facts
- Status
- A
- Type
- Organization
- Enumeration date
- 2024-05-09
- Last updated
- 2024-05-09
Licenses
The registry row did not include a license.
Location
- Practice location
- 2805 EAGLE DR
- City
- AMMON ID
- Postal code
- 834065769
- Phone
- 208-542-1333
Organization contact
- Name
- ANTHONY MONGILLO
- Title
- Manager
- Phone
- 2085421333
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.