=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356759781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO JOINT AND SPINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 09/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1760 N MITCHELL ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-322-5922
-----------------------------------------------------
Fax | 208-576-6932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1760 N MITCHELL ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-322-5922
-----------------------------------------------------
Fax | 208-576-6932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES A WHITAKER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 208-322-5922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number | O-0794
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | O-0794
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------