Healthcare Provider Details

I. General information

NPI: 1437866654
Provider Name (Legal Business Name): BOUNDARY MEDICINE & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7820 OLD HIGHWAY TWO LOOP
MOYIE SPRINGS ID
83845-5187
US

IV. Provider business mailing address

7820 OLD HIGHWAY TWO LOOP
MOYIE SPRINGS ID
83845-5187
US

V. Phone/Fax

Practice location:
  • Phone: 208-304-6401
  • Fax:
Mailing address:
  • Phone: 208-304-6401
  • Fax: 208-684-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MAYNARD BRYANT
Title or Position: OWNER
Credential: DO
Phone: 208-304-6401