Provider Demographics
NPI:1245243096
Name:TREASURE VALLEY SPINE & SPORTS CENTER, PLLC
Entity Type:Organization
Organization Name:TREASURE VALLEY SPINE & SPORTS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-672-0100
Mailing Address - Street 1:1450 S EAGLE FLIGHT WAY STE 150
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1562
Mailing Address - Country:US
Mailing Address - Phone:208-672-0100
Mailing Address - Fax:208-672-0200
Practice Address - Street 1:1450 S EAGLE FLIGHT WAY STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1562
Practice Address - Country:US
Practice Address - Phone:208-672-0100
Practice Address - Fax:208-672-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1159261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service