Healthcare Provider Details

I. General information

NPI: 1477321537
Provider Name (Legal Business Name): TREASURE VALLEY PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 W EVEREST LN STE 150
MERIDIAN ID
83646-6104
US

IV. Provider business mailing address

1067 E AZAN ST
MERIDIAN ID
83646-7682
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-4744
  • Fax: 844-402-0970
Mailing address:
  • Phone: 208-794-1559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TATIANA KHOCHAY
Title or Position: OWNER/PROVIDER
Credential: APRN-CRNA, NSPM-C
Phone: 208-794-1559