Healthcare Provider Details

I. General information

NPI: 1245243096
Provider Name (Legal Business Name): TREASURE VALLEY SPINE & SPORTS CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 S EAGLE FLIGHT WAY STE 150
BOISE ID
83709-1562
US

IV. Provider business mailing address

1450 S EAGLE FLIGHT WAY STE 150
BOISE ID
83709-1562
US

V. Phone/Fax

Practice location:
  • Phone: 208-672-0100
  • Fax: 208-672-0200
Mailing address:
  • Phone: 208-672-0100
  • Fax: 208-672-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberCHIA-1159
License Number StateID

VIII. Authorized Official

Name: DR. STEPHEN KYLE BURTENSHAW
Title or Position: OWNER/CHIROPRACTIC PHYSICIAN
Credential: D.C.
Phone: 208-672-0100