Healthcare Provider Details

I. General information

NPI: 1093796468
Provider Name (Legal Business Name): COEUR D' ALENE ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-2314
  • Fax: 208-262-2394
Mailing address:
  • Phone: 208-262-2314
  • Fax: 208-262-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: RONALD ROCK
Title or Position: PRESIDENT
Credential: CRNA
Phone: 208-262-2314