Provider Demographics
NPI:1275902520
Name:LANE, JACK IV (PTA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:LANE
Suffix:IV
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 1:615 29TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3341
Mailing Address - Country:US
Mailing Address - Phone:208-985-4722
Mailing Address - Fax:
Practice Address - Street 1:615 29TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3341
Practice Address - Country:US
Practice Address - Phone:208-985-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-3672314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility