Healthcare Provider Details

I. General information

NPI: 1063322782
Provider Name (Legal Business Name): INTERVENTIONAL PAIN ASSOCIATES P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

100 COTTONWOOD CT STE D150
EAGLE ID
83616-6576
US

IV. Provider business mailing address

100 COTTONWOOD CT STE D150
EAGLE ID
83616-6576
US

V. Phone/Fax

Practice location:
  • Phone: 208-917-2713
  • Fax: 208-955-2029
Mailing address:
  • Phone: 208-917-2713
  • Fax: 208-955-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA COLEMAN
Title or Position: MEMBER
Credential: CRNA
Phone: 951-264-2258