1467583153 NPI number — PAIN MANAGEMENT OF NORTH IDAHO, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467583153 NPI number — PAIN MANAGEMENT OF NORTH IDAHO, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT OF NORTH IDAHO, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467583153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1686 W RIVERSTONE DR
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-5779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-765-4807
Provider Business Mailing Address Fax Number:
866-573-0853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1686 W RIVERSTONE DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-5779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-4807
Provider Business Practice Location Address Fax Number:
208-765-2903
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOTAI
Authorized Official First Name:
TINA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
208-765-4807

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  M7860 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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