Healthcare Provider Details

I. General information

NPI: 1356759781
Provider Name (Legal Business Name): IDAHO JOINT AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 N MITCHELL ST
BOISE ID
83704-6542
US

IV. Provider business mailing address

1760 N MITCHELL ST
BOISE ID
83704-6542
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-5922
  • Fax: 208-576-6932
Mailing address:
  • Phone: 208-322-5922
  • Fax: 208-576-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberO-0794
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberO-0794
License Number StateID

VIII. Authorized Official

Name: JAMES A WHITAKER
Title or Position: OWNER
Credential: DO
Phone: 208-322-5922