Provider Demographics
NPI:1245628668
Name:DEEGEAR, ERIC (LMT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DEEGEAR
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 W PALOUSE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3534
Mailing Address - Country:US
Mailing Address - Phone:210-617-3399
Mailing Address - Fax:
Practice Address - Street 1:1007 N ORCHARD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2231
Practice Address - Country:US
Practice Address - Phone:210-617-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1611225700000X
TX110863225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist