Provider Demographics
NPI:1669664488
Name:POTTS, TERENCE KEVIN (LMT LLCC)
Entity Type:Individual
Prefix:MR
First Name:TERENCE
Middle Name:KEVIN
Last Name:POTTS
Suffix:
Gender:M
Credentials:LMT LLCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3943
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-3943
Mailing Address - Country:US
Mailing Address - Phone:208-450-7665
Mailing Address - Fax:208-578-2052
Practice Address - Street 1:16 W CROY ST
Practice Address - Street 2:SUITE K
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-9700
Practice Address - Country:US
Practice Address - Phone:208-450-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2896172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist