Healthcare Provider Details

I. General information

NPI: 1700180445
Provider Name (Legal Business Name): IDAHO SPORTS MEDICINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 W UNIVERSITY DR
BOISE ID
83706-3009
US

IV. Provider business mailing address

1188 W UNIVERSITY DR
BOISE ID
83706-3009
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-8250
  • Fax: 208-345-9514
Mailing address:
  • Phone: 208-336-8250
  • Fax: 208-345-9514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT-1825
License Number StateID

VIII. Authorized Official

Name: ROY TWEEDLE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 208-336-8250