Provider Demographics
NPI:1225368632
Name:COEUR D'ALENE SURGICAL AND VEIN
Entity Type:Organization
Organization Name:COEUR D'ALENE SURGICAL AND VEIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-664-4940
Mailing Address - Street 1:608 NORTHWEST BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2174
Mailing Address - Country:US
Mailing Address - Phone:208-664-4940
Mailing Address - Fax:208-664-5345
Practice Address - Street 1:608 NORTHWEST BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2174
Practice Address - Country:US
Practice Address - Phone:208-664-4940
Practice Address - Fax:208-664-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7963261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty