Healthcare Provider Details

I. General information

NPI: 1932871985
Provider Name (Legal Business Name): EVOLUTION JOINT PAIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E PLAZA DR STE 170
EAGLE ID
83616-6569
US

IV. Provider business mailing address

951 E PLAZA DR STE 170
EAGLE ID
83616-6569
US

V. Phone/Fax

Practice location:
  • Phone: 208-917-2928
  • Fax:
Mailing address:
  • Phone: 208-917-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEREMY LAMONT PAYNE
Title or Position: MEMBER
Credential: ND, DC
Phone: 208-917-2928