Provider Demographics
NPI:1477321537
Name:TREASURE VALLEY PAIN CENTER, LLC
Entity type:Organization
Organization Name:TREASURE VALLEY PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOCHAY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CRNA, NSPM-C
Authorized Official - Phone:208-794-1559
Mailing Address - Street 1:1067 E AZAN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7682
Mailing Address - Country:US
Mailing Address - Phone:208-794-1559
Mailing Address - Fax:
Practice Address - Street 1:2240 W EVEREST LN STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6104
Practice Address - Country:US
Practice Address - Phone:208-505-4744
Practice Address - Fax:844-402-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty