MEDICARE: DERRICK GEDDES LYONS PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT - 2994	ID

General Provider Information

NPI Number	:	1508263757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK GEDDES LYONS PT, DPT

Provider Business Mailing Address
First Line	:	1642 E ADELAIDE DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-9225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1642 E ADELAIDE DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-9225
Country	:	US
Telephone Number	:	904-540-8975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2014
Last Update Date	:	12/03/2014

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