Healthcare Provider Details

I. General information

NPI: 1992663595
Provider Name (Legal Business Name): ALTITUDE SPORT & SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 01/13/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1582 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1582 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-213-5256
  • Fax:
Mailing address:
  • Phone: 208-213-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA SIRUCEK
Title or Position: OWNER
Credential: DO
Phone: 208-213-5256