Healthcare Provider Details

I. General information

NPI: 1982940011
Provider Name (Legal Business Name): LUCAS BAHNMAIER MS, ATC/L, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W MYRTLE ST SUITE 200
BOISE ID
83702-6970
US

IV. Provider business mailing address

1109 W MYRTLE ST SUITE 200
BOISE ID
83702-6970
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-4299
  • Fax: 208-489-4300
Mailing address:
  • Phone: 208-489-4299
  • Fax: 208-489-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-425
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: