Provider Demographics
NPI:1598310278
Name:EINERSON, LANCE OLE (DPT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:OLE
Last Name:EINERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4533 S FOX CREEK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:440 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-380-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist