Healthcare Provider Details

I. General information

NPI: 1437150059
Provider Name (Legal Business Name): LYNN R JOHNSON PT; LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1611 N WHITLEY DR STE 1A
FRUITLAND ID
83619-2180
US

IV. Provider business mailing address

1560 S CAROL ST
MERIDIAN ID
83646-1839
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-0021
  • Fax: 208-452-0019
Mailing address:
  • Phone: 208-571-6739
  • Fax: 208-452-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT178
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: