Eastern Idaho Spine Center

Primary specialty

Rehabilitation PractitionerTaxonomy code 225400000X

Legal business name

EASTERN IDAHO SPINE CENTER

Practice address

2860 Channing Way
Ste 112
Idaho Falls, ID 83404-7531

Phone

(208) 535-4343

Fax

(208) 535-4344

NPI assigned

Mar 24, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Shane Christian Mangrum, M.D.

Title

Owner

Phone

(208) 535-4343

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1206316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1212710400000",
    "number": "1154593705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2860 CHANNING WAY",
            "address_2": "STE 112",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047531",
            "telephone_number": "208-535-4343",
            "fax_number": "208-535-4344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2860 CHANNING WAY",
            "address_2": "STE 112",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047531",
            "telephone_number": "208-535-4343",
            "fax_number": "208-535-4344"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTERN IDAHO SPINE CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-24",
        "last_updated": "2008-06-06",
        "status": "A",
        "authorized_official_last_name": "MANGRUM",
        "authorized_official_first_name": "SHANE",
        "authorized_official_middle_name": "CHRISTIAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-535-4343",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "225400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Rehabilitation Practitioner",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8079840",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Eastern Idaho Public Health District
• Eastern Idaho Reg Med Ctr PS, LLC
• Eastern Idaho Regional Medical Center
• Eastern Idaho Regional Medical Center Inpatient Services, LLC
• Eastern Idaho RMC Inpatient Services
• Eastgate Drug Inc
• Eastunder Therapy LLC
• Sandi De Eatinger, LCSW
• Colby C Ebanks, PT, DPT
• Ecetera Therapy Clinic

• Rehabilitation Practitioner in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Rehabilitation Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.