MEDICARE: LINDSEY E. DECLOSS M.S.P.T.

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	2387	ID

General Provider Information

NPI Number	:	1194822528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDSEY E. DECLOSS M.S.P.T.

Provider Business Mailing Address
First Line	:	801 E SAN PEDRO ST
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5650
Country	:	US
Telephone Number	:	208-991-8608
Fax Number	:

Provider Business Practice Location Address
First Line	:	9652 W STATE ST
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-5858
Country	:	US
Telephone Number	:	208-286-0766
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	01/07/2015

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