Healthcare Provider Details

I. General information

NPI: 1265527725
Provider Name (Legal Business Name): LON M. EGBERT, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 5TH AVE WEST
JEROME ID
83338
US

IV. Provider business mailing address

PO BOX 565
JEROME ID
83338
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-3090
  • Fax: 208-324-3093
Mailing address:
  • Phone: 208-324-3090
  • Fax: 208-324-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1686
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberPENDING
License Number StateID

VIII. Authorized Official

Name: MR. LON M EGBERT
Title or Position: PRESIDENT OWNER
Credential: PT, ATC
Phone: 208-324-3090