Provider Demographics
NPI:1104896422
Name:NORTH IDAHO PAIN CENTER LLC
Entity type:Organization
Organization Name:NORTH IDAHO PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOTAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-765-4807
Mailing Address - Street 1:1686 W RIVERSTONE DR
Mailing Address - Street 2:STE 2
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5779
Mailing Address - Country:US
Mailing Address - Phone:208-765-4807
Mailing Address - Fax:208-765-2903
Practice Address - Street 1:1686 W RIVERSTONE DR STE 2
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5779
Practice Address - Country:US
Practice Address - Phone:208-765-4807
Practice Address - Fax:208-765-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13C0001058261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870651Medicare ID - Type Unspecified