Provider Demographics
NPI:1982093357
Name:PAIN CARE CLINIC OF IDAHO, P.C.
Entity Type:Organization
Organization Name:PAIN CARE CLINIC OF IDAHO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-939-3750
Mailing Address - Street 1:742 E STATE ST
Mailing Address - Street 2:SIUITE 150
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5941
Mailing Address - Country:US
Mailing Address - Phone:208-939-3750
Mailing Address - Fax:208-939-3754
Practice Address - Street 1:742 E STATE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5941
Practice Address - Country:US
Practice Address - Phone:208-939-3750
Practice Address - Fax:208-939-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12565261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain