=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922731827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERMOUNTAIN REGENERATIVE MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2022
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 S UTAH AVE STE 200
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83402-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-218-8622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 S UTAH AVE STE 200
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83402-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-218-8622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARIE BARRS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-439-1512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------