Provider Demographics
NPI:1932946332
Name:IDAHO SPORT MASSAGE LLC
Entity type:Organization
Organization Name:IDAHO SPORT MASSAGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVANTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-580-9461
Mailing Address - Street 1:4846 HIRAM AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-3018
Mailing Address - Country:US
Mailing Address - Phone:435-580-9461
Mailing Address - Fax:
Practice Address - Street 1:675 YELLOWSTONE AVE # 1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4511
Practice Address - Country:US
Practice Address - Phone:208-478-1488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty