Provider Demographics
NPI:1821436718
Name:KINGHORN MEDICAL LLC
Entity Type:Organization
Organization Name:KINGHORN MEDICAL LLC
Other - Org Name:MOUNTAIN BRACE SYSTEMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:KINGHORN
Authorized Official - Suffix:
Authorized Official - Credentials:CO-F
Authorized Official - Phone:208-350-3092
Mailing Address - Street 1:248 S COLE RD
Mailing Address - Street 2:BLDG #7
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0934
Mailing Address - Country:US
Mailing Address - Phone:208-350-3092
Mailing Address - Fax:208-901-8185
Practice Address - Street 1:248 S COLE RD
Practice Address - Street 2:BLDG #7
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0934
Practice Address - Country:US
Practice Address - Phone:208-350-3092
Practice Address - Fax:208-901-8185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID009228Medicaid
ID7477070001Medicare NSC