Healthcare Provider Details

I. General information

NPI: 1093513566
Provider Name (Legal Business Name): ROAM IND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 N ECHOHAWK LN STE 104B
EAGLE ID
83616-4013
US

IV. Provider business mailing address

36 N ECHOHAWK LN STE 104B
EAGLE ID
83616-4013
US

V. Phone/Fax

Practice location:
  • Phone: 208-968-6700
  • Fax: 208-563-3938
Mailing address:
  • Phone: 208-968-6700
  • Fax: 208-563-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN P BRINK
Title or Position: OWNER
Credential: DC
Phone: 208-968-6700