1386188548 NPI number — BOISE SPINE & ORTHOPEDIC BRACING, LLC

Table of content: (NPI 1386188548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386188548 NPI number — BOISE SPINE & ORTHOPEDIC BRACING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOISE SPINE & ORTHOPEDIC BRACING, LLC
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:
1386188548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
757 E WYTHE CREEK CT
Provider Second Line Business Mailing Address:
102B
Provider Business Mailing Address City Name:
KUNA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83634-5006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-639-9329
Provider Business Mailing Address Fax Number:
208-881-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
757 E WYTHE CREEK CT
Provider Second Line Business Practice Location Address:
102B
Provider Business Practice Location Address City Name:
KUNA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83634-5006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-639-9329
Provider Business Practice Location Address Fax Number:
208-881-0103
Provider Enumeration Date:
12/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BURTENSHAW
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
KYLE
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
208-870-5209

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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)

  • Identifier: 7627500001 . This is a "NSC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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