Healthcare Provider Details

I. General information

NPI: 1578019063
Provider Name (Legal Business Name): ETHAN R EVERT P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 S 84TH ST STE 100
LINCOLN NE
68516-3909
US

IV. Provider business mailing address

PO BOX 67250
LINCOLN NE
68506-7250
US

V. Phone/Fax

Practice location:
  • Phone: 402-770-9775
  • Fax:
Mailing address:
  • Phone: 402-328-8833
  • Fax: 888-965-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2775
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: