Healthcare Provider Details

I. General information

NPI: 1235789249
Provider Name (Legal Business Name): HEALTH ATLAST POCATELLO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 FLANDRO DR STE 110
POCATELLO ID
83202-4936
US

IV. Provider business mailing address

1800 FLANDRO DR STE 110
POCATELLO ID
83202-4936
US

V. Phone/Fax

Practice location:
  • Phone: 208-242-3723
  • Fax: 208-904-1052
Mailing address:
  • Phone: 208-242-3723
  • Fax: 208-904-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHALOAM AGALELEI OFISA
Title or Position: OWNER
Credential: D.C., M.S.
Phone: 208-242-3723