Provider Demographics
NPI:1851571376
Name:CRANIOSPINAL INSTITUTE PLLC
Entity Type:Organization
Organization Name:CRANIOSPINAL INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-4343
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:STE 114
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4343
Mailing Address - Fax:208-535-4344
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:STE 114
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-535-4343
Practice Address - Fax:208-535-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty