Healthcare Provider Details

I. General information

NPI: 1194598102
Provider Name (Legal Business Name): HEAD SPORT EM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
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: 208-512-4334
  • Fax:
Mailing address:
  • Phone: 208-215-2030
  • Fax: 208-400-9537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

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