Individual
MR. JACK LANE IV
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
615 29TH ST, LEWISTON, ID 83501-3341
(208) 985-4722
Mailing address
615 29TH ST, LEWISTON, ID 83501-3341
(208) 985-4722
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
PTA-3672
ID
Other
Enumeration date
09/16/2015
Last updated
09/16/2015
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