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IDAHO PAIN MEDICINE

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Company Details

Name: IDAHO PAIN MEDICINE
Jurisdiction: Idaho
Legal type: Assumed Business Name
Status: Active-Current
Date of registration: 26 May 2000 (25 years ago)
Entity Number: 121076
Place of Formation: IDAHO
File Number: 0000121076
ZIP code: 83704
County: Ada County
Mailing Address: 8620 W EMERALD STE 120 BOISE, ID 83704

National Provider Identifier

NPI Number:
1588832992

Authorized Person:

Name:
DR. SHANE ALAN MAXWELL
Role:
CO-OWNER
Phone:

Taxonomy:

Selected Taxonomy:
208VP0014X - Interventional Pain Medicine Physician
Is Primary:
Yes

Contacts:

Fax:
2083236277

Filing

Filing Name Filing Number Filing date
Initial Filing 0000121076 2000-05-26

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Date of last update: 23 Sep 2024

Sources: Idaho Secretary of State