Provider Demographics
NPI:1386188548
Name:BOISE SPINE & ORTHOPEDIC BRACING, LLC
Entity type:Organization
Organization Name:BOISE SPINE & ORTHOPEDIC BRACING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-870-5209
Mailing Address - Street 1:757 E WYTHE CREEK CT
Mailing Address - Street 2:102B
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5006
Mailing Address - Country:US
Mailing Address - Phone:208-639-9329
Mailing Address - Fax:208-881-0103
Practice Address - Street 1:757 E WYTHE CREEK CT
Practice Address - Street 2:102B
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5006
Practice Address - Country:US
Practice Address - Phone:208-639-9329
Practice Address - Fax:208-881-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7627500001OtherNSC