Healthcare Provider Details

I. General information

NPI: 1114929817
Provider Name (Legal Business Name): TERRI L HALEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 OAK ST
SANDPOINT ID
83864-1480
US

IV. Provider business mailing address

514 OAK ST
SANDPOINT ID
83864-1480
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-7965
  • Fax: 208-265-7965
Mailing address:
  • Phone: 208-265-7965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100004
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: