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GEM STATE ENT, PLLC

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Company Details

Name: GEM STATE ENT, PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 01 Jun 2010 (15 years ago)
Financial Date End: 30 Jun 2026
Entity Number: 290766
Place of Formation: IDAHO
File Number: 290766
ZIP code: 83301
County: Twin Falls County
Principal Address: PO BOX 1293 TWIN FALLS, ID 83303
Mailing Address: 2102 CANYON PLAZA DR TWIN FALLS, ID 83301-4513

Agent

Name Role Address
JOHN A COLEMAN Agent 401 GOODING ST N STE 201, TWIN FALLS, ID 83301

Manager

Name Role Address Appointed On Resigned On
Russell Mayes Manager PO BOX 1293, TWIN FALLS, ID 83303 2021-05-19 No data
Kylan Peterson Manager PO BOX 1293, TWIN FALLS, ID 83303 2024-05-10 2024-05-10

U.S. Small Business Administration Profile

Phone Number:
E-mail Address:
Fax Number:
208-352-7333
Contact Person:
ALI MOORE
User ID:
P3311662

Unique Entity ID

Unique Entity ID:
XWJSNJBQU898
CAGE Code:
9ZM36
UEI Expiration Date:
2026-06-23

Business Information

Division Name:
GEM STATE ENT AND HEARING PROFESSIONALS
Activation Date:
2025-06-25
Initial Registration Date:
2024-08-02

National Provider Identifier

NPI Number:
1215715669
Certification Date:
2025-04-08

Authorized Person:

Name:
BROOKE FREIDENBERGER
Role:
MEDICAL CODER
Phone:

Taxonomy:

Selected Taxonomy:
208D00000X - General Practice Physician
Is Primary:
Yes

Contacts:

Fax:
2088041707
Fax:
2083527333

Filing

Filing Name Filing Number Filing date
Statement of Change of Business Mailing Address 0006323780 2025-06-18
Annual Report 0006247625 2025-05-09
Statement of Change of Business Mailing Address 0005862920 2024-08-15
Annual Report 0005734289 2024-05-10
Annual Report 0005221886 2023-05-03

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Date of last update: 18 Jul 2025

Sources: Idaho Secretary of State