Provider Demographics
NPI:1740883172
Name:BOOST VENTURES PLLC
Entity type:Organization
Organization Name:BOOST VENTURES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALBRAITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-313-7569
Mailing Address - Street 1:36 N 2ND W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1515
Mailing Address - Country:US
Mailing Address - Phone:208-313-7569
Mailing Address - Fax:
Practice Address - Street 1:36 N 2ND W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1515
Practice Address - Country:US
Practice Address - Phone:208-313-7569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty