Healthcare Provider Details

I. General information

NPI: 1922431360
Provider Name (Legal Business Name): COEUR D ALENE PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 W IRONWOOD DR STE 200
COEUR D ALENE ID
83814-2643
US

IV. Provider business mailing address

920 W IRONWOOD DR STE 200
COEUR D ALENE ID
83814-2643
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-2600
  • Fax: 208-625-2051
Mailing address:
  • Phone: 208-667-2600
  • Fax: 208-625-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-431
License Number StateID

VIII. Authorized Official

Name: BRANDON RICE
Title or Position: OWNER
Credential:
Phone: 208-667-2600