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SPINE INSTITUTE OF IDAHO, P.A.

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Company Details

Name: SPINE INSTITUTE OF IDAHO, P.A.
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Active-Good Standing
Date of registration: 13 Mar 2001 (24 years ago)
Financial Date End: 31 Mar 2026
Entity Number: 421371
Place of Formation: IDAHO
File Number: 421371
ZIP code: 83642
County: Ada County
Mailing Address: 360 E MONTVUE DR # 100 MERIDIAN, ID 83642-6318

Agent

Name Role Address
Jennifer Harris Agent 360 E MONTVUE DR, 100, MERIDIAN, ID 83642

President

Name Role Address Appointed On
SAMUEL S JORGENSON President 360 E MONTVUE, MERIDIAN, ID 83642 2021-04-06
Michael Spackman President 360 E MONTVUE DR, MERIDIAN, ID 83642 2025-02-25

Unique Entity ID

A UEI is a government-provided number, like a tax ID number, that’s used to identify businesses eligible for federal grants, awards and contracts.

Note: In April 2022, the federal government replaced its old identifier of choice, the Data Universal Numbering System (DUNS) number, with a government-issued UEI. Now all the federal government’s Integrated Award Environment systems use UEI numbers instead of DUNS numbers. So any entity doing business with the federal government must register for a UEI.

CAGE Code:
86BY8
UEI Expiration Date:
2020-09-15

Business Information

Activation Date:
2019-09-16
Initial Registration Date:
2018-09-17

National Provider Identifier

NPI Number:
1659380269

Authorized Person:

Name:
MR. TYLER COOPER
Role:
OFFICE ASST ADMINISTRATOR
Phone:

Taxonomy:

Selected Taxonomy:
207XS0117X - Orthopaedic Surgery of the Spine Physician
Is Primary:
Yes

Contacts:

Fax:
2088989877

Form 5500 Series

Employer Identification Number (EIN):
820531056
Plan Year:
2023
Number Of Participants:
42
Sponsors Telephone Number:
Plan Year:
2022
Number Of Participants:
46
Sponsors Telephone Number:
Plan Year:
2021
Number Of Participants:
46
Sponsors Telephone Number:
Plan Year:
2020
Number Of Participants:
42
Sponsors Telephone Number:
Plan Year:
2019
Number Of Participants:
47
Sponsors Telephone Number:

Filing

Filing Name Filing Number Filing date
Annual Report 0006127997 2025-02-25
Articles of Amendment 0006049496 2025-01-20
Annual Report 0005585618 2024-02-05
Annual Report 0005091982 2023-02-03
Annual Report 0004600185 2022-02-08

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Date of last update: 30 Jun 2025

Sources: Idaho Secretary of State