Provider Demographics
NPI:1346698701
Name:IEG ZENERGY, LLC
Entity Type:Organization
Organization Name:IEG ZENERGY, LLC
Other - Org Name:ZENERGY SPORTS REHABILITATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:AGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-725-5384
Mailing Address - Street 1:PO BOX 1363
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-1363
Mailing Address - Country:US
Mailing Address - Phone:208-726-7246
Mailing Address - Fax:208-726-8911
Practice Address - Street 1:245 RAVEN RD
Practice Address - Street 2:SUITE B
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-7246
Practice Address - Fax:208-726-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty