Organization
EASTERN IDAHO SPINE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHANE CHRISTIAN MANGRUM M.D. (OWNER)
(208) 535-4343
Entity
Organization
Contact information
Practice address
2860 CHANNING WAY, STE 112, IDAHO FALLS, ID 83404-7531
(208) 535-4343
(208) 535-4344
Mailing address
2860 CHANNING WAY, STE 112, IDAHO FALLS, ID 83404-7531
(208) 535-4343
(208) 535-4344
Taxonomy
Speciality
Code
Description
License number
State
225400000X
Rehabilitation Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8079840
—
ID
Enumeration date
03/24/2008
Last updated
06/06/2008
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