Provider Demographics
NPI:1891104014
Name:IDAHO JOINT AND SPINE, PC
Entity Type:Organization
Organization Name:IDAHO JOINT AND SPINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:AROET
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-322-5922
Mailing Address - Street 1:9510 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8103
Mailing Address - Country:US
Mailing Address - Phone:208-322-5922
Mailing Address - Fax:208-323-1386
Practice Address - Street 1:9510 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8103
Practice Address - Country:US
Practice Address - Phone:208-322-5922
Practice Address - Fax:208-323-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0794261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty