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General NPI Number Information
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NPI Number | 1588714489
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Entity Type | Organization
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Legal Business Name | COEUR D ALENE SPINE AND BRAIN PLLC
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 02/23/2023
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Provider Practice Location Address
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Address Line | 3320 N GRAND MILL LN
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City | COEUR D ALENE
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State | ID
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Zip | 83814-5689
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Country | US
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Telephone | 208-765-9100
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Fax | 208-765-9103
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Provider Business Mailing Address
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Address Line | 3320 N GRAND MILL LN
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City | COEUR D ALENE
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State | ID
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Zip | 83814-5689
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Country | US
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Telephone | 208-765-9100
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Fax | 208-765-9103
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | LISA RAE TANSY
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Credential |
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Telephone | 208-765-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M8677
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License Number State | ID
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