Healthcare Provider Details

I. General information

NPI: 1891460754
Provider Name (Legal Business Name): BACK PAIN SOLUTIONS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

IV. Provider business mailing address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

V. Phone/Fax

Practice location:
  • Phone: 208-660-9378
  • Fax: 208-758-8527
Mailing address:
  • Phone: 208-660-9378
  • Fax: 208-758-8527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER BOWMAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 280-967-5608