Healthcare Provider Details

I. General information

NPI: 1619539897
Provider Name (Legal Business Name): NORTHWEST OCCUPATIONAL MEDICINE & NEUROSURGICAL SPINE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8921 W HACKAMORE DR
BOISE ID
83709-1673
US

IV. Provider business mailing address

6140 W CURTISIAN AVE STE 400
BOISE ID
83704-8907
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-1105
  • Fax: 208-377-7707
Mailing address:
  • Phone: 208-327-5631
  • Fax: 208-327-5602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL JOSEPH MONTALBANO
Title or Position: OWNER
Credential: MD
Phone: 208-327-5600