Healthcare Provider Details

I. General information

NPI: 1871463141
Provider Name (Legal Business Name): BENJAMIN THOMAS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N NORTHWOOD CENTER CT STE 101
COEUR D ALENE ID
83814-6190
US

IV. Provider business mailing address

1233 N NORTHWOOD CENTER CT STE 101
COEUR D ALENE ID
83814-6190
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-4211
  • Fax: 208-773-1473
Mailing address:
  • Phone: 208-457-4211
  • Fax: 208-773-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number63763
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: