Healthcare Provider Details

I. General information

NPI: 1598068280
Provider Name (Legal Business Name): PIONEER SPORTS & PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 E WYTHE CREEK CT STE 102
KUNA ID
83634-5006
US

IV. Provider business mailing address

757 E WYTHE CREEK CT STE 102
KUNA ID
83634-5006
US

V. Phone/Fax

Practice location:
  • Phone: 208-922-4908
  • Fax: 208-922-4909
Mailing address:
  • Phone: 208-922-4908
  • Fax: 208-922-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIA-1159
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN KYLE BURTENSHAW
Title or Position: OWNER
Credential:
Phone: 208-922-4908