Provider Demographics
NPI:1265527725
Name:LON M. EGBERT, P.C.
Entity type:Organization
Organization Name:LON M. EGBERT, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LON
Authorized Official - Middle Name:M
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:208-324-3090
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338
Mailing Address - Country:US
Mailing Address - Phone:208-324-3090
Mailing Address - Fax:208-324-3093
Practice Address - Street 1:128 5TH AVE WEST
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-324-3090
Practice Address - Fax:208-324-3093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPENDING2255A2300X
IDPT-1686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid
IDPENDINGMedicaid