Healthcare Provider Details

I. General information

NPI: 1629392154
Provider Name (Legal Business Name): KOOTENAI URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E MULLAN AVE SUITE 600
POST FALLS ID
83854-6052
US

IV. Provider business mailing address

700 W IRONWOOD DR SUITE 272E
COEUR D ALENE ID
83814-2656
US

V. Phone/Fax

Practice location:
  • Phone: 208-777-9110
  • Fax: 208-777-1871
Mailing address:
  • Phone: 208-676-0145
  • Fax: 208-676-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERIC KOELSCH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-676-0145