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General NPI Number Information
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NPI Number | 1891460754
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Entity Type | Organization
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Legal Business Name | BACK PAIN SOLUTIONS CLINIC INC
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Dates
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Enumeration Date | 08/12/2021
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Last Update Date | 08/18/2021
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Provider Practice Location Address
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Address Line | 827 W PRAIRIE AVE
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City | HAYDEN
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State | ID
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Zip | 83835-8459
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Country | US
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Telephone | 208-660-9378
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Fax | 208-758-8527
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Provider Business Mailing Address
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Address Line | 827 W PRAIRIE AVE
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City | HAYDEN
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State | ID
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Zip | 83835-8459
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Country | US
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Telephone | 208-660-9378
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Fax | 208-758-8527
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | CHRISTOPHER BOWMAN
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Credential |
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Telephone | 280-967-5608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | 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 | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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