Healthcare Provider Details

I. General information

NPI: 1942116884
Provider Name (Legal Business Name): OWN FAMILY MEDICINE AND WELLNESS LLC DBA ACTIVE FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

IV. Provider business mailing address

919 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-0560
  • Fax: 208-762-5424
Mailing address:
  • Phone: 208-758-0560
  • Fax: 208-762-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TANNER SOUZA
Title or Position: OWNER
Credential: DO
Phone: 702-769-8819