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EASTERN IDAHO SPINE CENTER PLLC

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Company Details

Name: EASTERN IDAHO SPINE CENTER PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 11 Feb 2008 (17 years ago)
Financial Date End: 28 Feb 2017
Date dissolved: 05 Jun 2017
Entity Number: 224212
Place of Formation: IDAHO
File Number: 0000224212
ZIP code: 83404
County: Bonneville County
Principal Address: 2730 HOMESTEAD LN IDAHO FALLS, ID 83404

National Provider Identifier

NPI Number:
1154593705

Authorized Person:

Name:
DR. SHANE CHRISTIAN MANGRUM
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
225400000X - Rehabilitation Practitioner
Is Primary:
Yes

Contacts:

Fax:
2085354344

Form 5500 Series

Employer Identification Number (EIN):
261906740
Plan Year:
2014
Number Of Participants:
6
Sponsors Telephone Number:
Plan Year:
2013
Number Of Participants:
4
Sponsors Telephone Number:
Plan Year:
2012
Number Of Participants:
4
Sponsors Telephone Number:
Plan Year:
2011
Number Of Participants:
4
Sponsors Telephone Number:
Plan Year:
2010
Number Of Participants:
4
Sponsors Telephone Number:

Filing

Filing Name Filing Number Filing date
Annual Report 0001820309 2015-12-21
Change of Registered Office/Agent/Both (by Entity) 0001820308 2015-04-06
Statement of Change of Business Mailing Address 0001820307 2015-04-06
Legacy Amendment 0000807216 2015-04-03
Annual Report 0001820306 2015-02-04

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Date of last update: 24 Sep 2024

Sources: Idaho Secretary of State