Provider Demographics
NPI:1437866654
Name:BOUNDARY MEDICINE & WELLNESS, LLC
Entity Type:Organization
Organization Name:BOUNDARY MEDICINE & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MAYNARD
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-304-6401
Mailing Address - Street 1:7820 OLD HIGHWAY TWO LOOP
Mailing Address - Street 2:
Mailing Address - City:MOYIE SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83845-5187
Mailing Address - Country:US
Mailing Address - Phone:208-304-6401
Mailing Address - Fax:208-684-7115
Practice Address - Street 1:7820 OLD HIGHWAY TWO LOOP
Practice Address - Street 2:
Practice Address - City:MOYIE SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83845-5187
Practice Address - Country:US
Practice Address - Phone:208-304-6401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-28
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty