Provider Demographics
NPI:1558974196
Name:TERRELL, ROBERT ERNEST
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ERNEST
Last Name:TERRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 TAMARACK DR APT 104
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4734
Mailing Address - Country:US
Mailing Address - Phone:208-541-4611
Mailing Address - Fax:
Practice Address - Street 1:823 TAMARACK DR APT 104
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4734
Practice Address - Country:US
Practice Address - Phone:208-541-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
344600000X
IDYC366228D347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No344600000XTransportation ServicesTaxi