Provider Demographics
NPI:1619998648
Name:PAIN CARE CENTER BOISE, LLC
Entity Type:Organization
Organization Name:PAIN CARE CENTER BOISE, LLC
Other - Org Name:PAIN CARE BOISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:BINEGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-342-8200
Mailing Address - Street 1:301 W MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7656
Mailing Address - Country:US
Mailing Address - Phone:208-342-8200
Mailing Address - Fax:208-342-8202
Practice Address - Street 1:301 W MYRTLE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7656
Practice Address - Country:US
Practice Address - Phone:208-342-8200
Practice Address - Fax:208-343-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806893300Medicaid
ID1870556Medicare PIN