Provider Demographics
NPI:1386246122
Name:BOOST ORTHOPEDICS AND SPORTS MEDICINE CONSULTING
Entity type:Organization
Organization Name:BOOST ORTHOPEDICS AND SPORTS MEDICINE CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-410-5081
Mailing Address - Street 1:PO BOX 1236
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-1231
Mailing Address - Country:US
Mailing Address - Phone:541-410-5081
Mailing Address - Fax:208-203-1893
Practice Address - Street 1:241 SKIWAY DRIVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-8334
Practice Address - Country:US
Practice Address - Phone:541-410-5081
Practice Address - Fax:208-203-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty