Provider Demographics
NPI:1700180445
Name:IDAHO SPORTS MEDICINE INSTITUTE
Entity Type:Organization
Organization Name:IDAHO SPORTS MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:TWEEDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-336-8250
Mailing Address - Street 1:1188 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3009
Mailing Address - Country:US
Mailing Address - Phone:208-336-8250
Mailing Address - Fax:208-345-9514
Practice Address - Street 1:1188 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3009
Practice Address - Country:US
Practice Address - Phone:208-336-8250
Practice Address - Fax:208-345-9514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1825261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy