Healthcare Provider Details

I. General information

NPI: 1982093357
Provider Name (Legal Business Name): PAIN CARE CLINIC OF IDAHO, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 E STATE ST SUITE 150
EAGLE ID
83616-5941
US

IV. Provider business mailing address

742 E STATE ST SIUITE 150
EAGLE ID
83616-5941
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3750
  • Fax: 208-939-3754
Mailing address:
  • Phone: 208-939-3750
  • Fax: 208-939-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberM12565
License Number StateID

VIII. Authorized Official

Name: EDMUND C BOESE
Title or Position: OWNER
Credential: MD
Phone: 208-939-3750