Provider Demographics
NPI:1003564998
Name:MAGIC VALLEY PAIN SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:MAGIC VALLEY PAIN SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-678-7246
Mailing Address - Street 1:PO BOX 50979
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-0979
Mailing Address - Country:US
Mailing Address - Phone:208-678-7246
Mailing Address - Fax:
Practice Address - Street 1:1344 HILAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-678-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty