Provider Demographics
NPI:1174816144
Name:COEUR D' ALENE FOOT & ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:COEUR D' ALENE FOOT & ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DPM
Authorized Official - Phone:208-666-0605
Mailing Address - Street 1:101 W IRONWOOD DR
Mailing Address - Street 2:SUITE 131
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1409
Mailing Address - Country:US
Mailing Address - Phone:208-666-0605
Mailing Address - Fax:208-666-0916
Practice Address - Street 1:101 W IRONWOOD DR
Practice Address - Street 2:SUITE 131
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-1409
Practice Address - Country:US
Practice Address - Phone:208-666-0605
Practice Address - Fax:208-666-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6585680001Medicare NSC