Healthcare Provider Details

I. General information

NPI: 1548194715
Provider Name (Legal Business Name): MR. TERRELL LEE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST
BOISE ID
83705-1966
US

IV. Provider business mailing address

1754 N FIREBRICK DR
KUNA ID
83634-5027
US

V. Phone/Fax

Practice location:
  • Phone: 208-919-4692
  • Fax: 208-506-7865
Mailing address:
  • Phone: 520-683-6347
  • Fax: 208-506-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: