Provider Demographics
NPI:1003500802
Name:LANE, JEFF S (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:S
Last Name:LANE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:HORNER
Mailing Address - State:WV
Mailing Address - Zip Code:26372-9687
Mailing Address - Country:US
Mailing Address - Phone:304-517-0271
Mailing Address - Fax:
Practice Address - Street 1:67 CASINO DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ANMORE
Practice Address - State:WV
Practice Address - Zip Code:26323
Practice Address - Country:US
Practice Address - Phone:304-622-2684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000946225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant