Healthcare Provider Details

I. General information

NPI: 1538514088
Provider Name (Legal Business Name): LYONS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 S 13TH ST UNIT 6581
BOISE ID
83707-0002
US

IV. Provider business mailing address

PO BOX 6581
BOISE ID
83707-0581
US

V. Phone/Fax

Practice location:
  • Phone: 208-484-2134
  • Fax:
Mailing address:
  • Phone: 208-484-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1156
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number1156
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number1156
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number1156
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1156
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number1156
License Number StateID

VIII. Authorized Official

Name: MR. EUGENE C LYONS
Title or Position: OWNER
Credential: PT
Phone: 208-484-2134