Healthcare Provider Details

I. General information

NPI: 1821036724
Provider Name (Legal Business Name): INTERMOUNTAIN SPINE AND ORTHOPEDICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 FALLS AVE E SUITE 1301
TWIN FALLS ID
83301-3455
US

IV. Provider business mailing address

1411 FALLS AVE E STE 1301
TWIN FALLS ID
83301-3467
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-0067
  • Fax: 208-732-3195
Mailing address:
  • Phone: 208-732-0067
  • Fax: 208-732-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID M CHRISTENSEN
Title or Position: OWNER
Credential: MD
Phone: 208-732-0067