Healthcare Provider Details

I. General information

NPI: 1104731561
Provider Name (Legal Business Name): OFF THE FIELD SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 E LANARK ST
MERIDIAN ID
83642-5916
US

IV. Provider business mailing address

2204 E LANARK ST
MERIDIAN ID
83642-5916
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-0200
  • Fax:
Mailing address:
  • Phone: 208-466-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDY ROLL
Title or Position: BILLING
Credential:
Phone: 208-466-0200