Healthcare Provider Details

I. General information

NPI: 1215238795
Provider Name (Legal Business Name): SYNERGY PAIN MANAGEMENT AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 E PLAZA DR
EAGLE ID
83616-6548
US

IV. Provider business mailing address

PO BOX 434
EAGLE ID
83616-0434
US

V. Phone/Fax

Practice location:
  • Phone: 208-229-7075
  • Fax: 208-229-7076
Mailing address:
  • Phone: 208-229-7075
  • Fax: 208-229-7076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STACY OSTLER
Title or Position: OWNER
Credential: MD
Phone: 208-229-7075