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IDAHO SPORTS & SPINE PLLC

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Company Details

Name: IDAHO SPORTS & SPINE PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 18 Oct 2007 (18 years ago)
Financial Date End: 31 Oct 2025
Entity Number: 214029
Place of Formation: IDAHO
File Number: 214029
ZIP code: 83201
County: Bannock County
Principal Address: STE A 950 HOSPITAL WAY POCATELLO, ID 83201-2762

Agent

Name Role Address
STEPHEN HANSEN Agent 950 HOSPITAL WAY, STE A, POCATELLO, ID 83201

Member

Name Role Address Appointed On Resigned On
Stephen Hansen Member 950 HOSPITAL WAY, POCATELLO, ID 83201-2762 2021-08-02 No data
Luke Nelson Member 950 HOSPITAL WAY, POCATELLO, ID 83201-2762 2023-11-06 2023-11-06

Manager

Name Role Address Appointed On Resigned On
Amanda L Chatterton Manager 950 HOSPITAL WAY, POCATELLO, ID 83201 2020-09-08 2021-08-02

National Provider Identifier

NPI Number:
1033417035

Authorized Person:

Name:
STEPHEN HANSEN
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
207QS0010X - Sports Medicine (Family Medicine) Physician
Is Primary:
Yes

Contacts:

Fax:
2084782935

Filing

Filing Name Filing Number Filing date
Annual Report 0005935853 2024-10-10
Annual Report 0005467174 2023-11-06
Annual Report 0004958521 2022-10-21
Annual Report 0004457205 2021-10-21
Statement of Correction 0004446120 2021-10-13

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Date of last update: 29 May 2025

Sources: Idaho Secretary of State