Coeur D Alene Primary Care PLLC
Organization Active NPI Primary Care Clinic/Center · Coeur D Alene, ID
NPI 1922431360 · NPPES record last updated Dec 29, 2022
Key facts
- NPI
- 1922431360
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Primary Care Clinic/Center 261QP2300X
- Legal business name
- COEUR D ALENE PRIMARY CARE PLLC
- Practice address
- 920 W Ironwood Dr Ste 200
Coeur D Alene, ID 83814-2643 - Phone
- (208) 667-2600
- Fax
- (208) 625-2051
- NPI assigned
- Aug 20, 2013
- Organization subpart
- No
Authorized official
- Name
- Brandon Rice
- Title
- Owner
- Phone
- (208) 667-2600
Practitioners 19
-
Amy Bishop, RN
-
Teirza D Bristow, ARNP
-
Suzanne Marie Decker, APN
-
Aimee M Goold, ARNP, FNP-BC
-
Christina May Hatley, ARNP, CNM
-
Patricia Ann Woods, NURSE PRACTITIONER
-
Robert Jordan Lakko, D.O.
-
Zachary Daniel Harman, APRN
-
Kristy Graham, FNP-BC
-
Christy Lynn Sutton, FNP
-
Marissa Lisette Cadena, PA-C
-
McKenzie Gale, DNP, ARNP, FNP-C
-
Rachel Ewing, RDN, LD
-
Mikyah Hope Owens, RDN, LD
-
Jordan B Wolff, CRNA
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D2077897 | Coeur D'Alene Primary Care | Certificate of waiver | May 15, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20140111000034 | ID | Part B Supplier - Clinic/Group Practice | 8729216171 |
Receives reassigned benefits from 14 practitioners Practice locations: Kellogg, ID; Coeur D Alene, ID |
National Provider Directory
Locations
920 W Ironwood Dr
Ste 200
Coeur D Alene, ID 83814
Phone (208) 667-2600
1025 W Ironwood Dr
Coeur D Alene, ID 83814
Phone (208) 667-2600
1025 W Ironwood Dr
Ste 3
Coeur D Alene, ID 83814
Phone (208) 667-2600
2065 W Riverstone Dr
Ste 203
Coeur D Alene, ID 83814
Phone (208) 215-2150
100 McKinley Ave
Kellogg, ID 83837
Phone (208) 586-5588
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Primary Care Clinic/Center | 261QP2300X | Yes | ||
| Physician Assistant |
363A00000X | PA-431 | ID |
Addresses
Primary practice location
920 W Ironwood Dr Ste 200
Coeur D Alene, ID 83814-2643
Mailing address
920 W Ironwood Dr Ste 200
Coeur D Alene, ID 83814-2643
Phone (208) 667-2600
Other practice location 1
2065 W Riverstone Dr
Suite 203
Coeur D Alene, ID 83814-5699
Phone (208) 215-2045
Other names
- COEUR D ALENE PRIMARY CARE PLLC
Other providers in Coeur D Alene, ID
- Coeur D Alene Massage School LLC
- Coeur D Alene of Cascadia
- Coeur D Alene Optical, Inc.
- Coeur D Alene Physical Therapy and Sports Medicine PA
- Coeur D Alene Plastic Surgery PLLC
- Coeur D Alene Spine and Brain PLLC
- Coeur D Mind
- Coeur D' Alene Foot & Ankle Clinic LLC
- Coeur D' Alene Oral Surgery
- Coeur D'Alene Denture Clinic LLC
All providers in Coeur D Alene, ID · Primary Care Clinic/Center in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 29, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.