Healthcare Provider Details

I. General information

NPI: 1386279321
Provider Name (Legal Business Name): RODERIC RINGHAND LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6795 N MINERAL DR
COEUR D ALENE ID
83815-8700
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-4222
  • Fax: 844-803-7399
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-620-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33493
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: