Provider Demographics
NPI:1922431360
Name:COEUR D ALENE PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:COEUR D ALENE PRIMARY CARE PLLC
Other - Org Name:COEUR D ALENE PRIMARY CARE PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-2600
Mailing Address - Street 1:920 W IRONWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2643
Mailing Address - Country:US
Mailing Address - Phone:208-667-2600
Mailing Address - Fax:208-625-2051
Practice Address - Street 1:920 W IRONWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2643
Practice Address - Country:US
Practice Address - Phone:208-667-2600
Practice Address - Fax:208-625-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
IDPA-431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty