Healthcare Provider Details

I. General information

NPI: 1407354574
Provider Name (Legal Business Name): PRIME SPORTS MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 12TH AVE RD SUITE 101
NAMPA ID
83686-5015
US

IV. Provider business mailing address

1601 12TH AVE RD SUITE 101
NAMPA ID
83686-5015
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1618
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB BOWER
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 208-466-0200