Healthcare Provider Details

I. General information

NPI: 1710515176
Provider Name (Legal Business Name): ANDREW JOHN COYLE LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 1343
SANDPOINT ID
83864-0863
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1441
  • Fax: 208-265-6270
Mailing address:
  • Phone: 208-263-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1181
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: