Provider Demographics
NPI:1154593705
Name:EASTERN IDAHO SPINE CENTER
Entity type:Organization
Organization Name:EASTERN IDAHO SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-4343
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:STE 112
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4343
Mailing Address - Fax:208-535-4344
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:STE 112
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-535-4343
Practice Address - Fax:208-535-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8079840Medicaid