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General NPI Number Information
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NPI Number | 1093513566
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Entity Type | Organization
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Legal Business Name | ROAM IND LLC
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 36 N ECHOHAWK LN STE 104B
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City | EAGLE
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State | ID
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Zip | 83616-4013
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Country | US
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Telephone | 208-968-6700
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Fax | 208-563-3938
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Provider Business Mailing Address
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Address Line | 36 N ECHOHAWK LN STE 104B
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City | EAGLE
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State | ID
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Zip | 83616-4013
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Country | US
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Telephone | 208-968-6700
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Fax | 208-563-3938
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTIN P BRINK
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Credential | DC
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Telephone | 208-968-6700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number |
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License Number State |
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