Healthcare Provider Details

I. General information

NPI: 1508611591
Provider Name (Legal Business Name): ADVANCED ORTHOPEDICS AND SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 208-731-2351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHAD JOHNSON
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 208-731-2351