Healthcare Provider Details

I. General information

NPI: 1073403051
Provider Name (Legal Business Name): BOISE BRAIN AND BODY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N CURTIS RD
BOISE ID
83706-1445
US

IV. Provider business mailing address

6568 S FEDERAL WAY # 238
BOISE ID
83716-9277
US

V. Phone/Fax

Practice location:
  • Phone: 208-605-3000
  • Fax:
Mailing address:
  • Phone: 818-861-6481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD A ANTON
Title or Position: OWNER
Credential:
Phone: 818-861-6481