MEDICARE: UPRIVER MYOPRACTIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1952116519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPRIVER MYOPRACTIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 204
Second Line	:
City	:	SANTA
State	:	ID
Zip	:	83866-0204
Country	:	US
Telephone Number	:	208-295-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 EAST DAVIS STREET
Second Line	:
City	:	SANTA
State	:	ID
Zip	:	83866-8386
Country	:	US
Telephone Number	:	208-295-9500
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	MR. JAMES COLIN GRADY
Credential	:	LMT
Telephone Number	:	208-295-9500

Provider Enumeration Date	:	02/11/2025
Last Update Date	:	02/11/2025

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