Healthcare Provider Details

I. General information

NPI: 1578337044
Provider Name (Legal Business Name): HEALTH SPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 206
COEUR D ALENE ID
83814-2668
US

IV. Provider business mailing address

980 W IRONWOOD DR STE 206
COEUR D ALENE ID
83814-2668
US

V. Phone/Fax

Practice location:
  • Phone: 208-215-2030
  • Fax: 208-400-9537
Mailing address:
  • Phone: 208-215-2030
  • Fax: 208-400-9537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: WENDY PANOS
Title or Position: OWNER
Credential:
Phone: 208-215-2030