Individual
LON MIGUEL EGBERT
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PT, ATC
Contact information
Practice address
128 5TH AVE W, JEROME, ID 83338-1863
(208) 324-3090
(208) 324-3093
Mailing address
3121 EAGLE RIDGE DR, WENDELL, ID 83355-3340
(208) 536-2135
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT1686
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010140741
BLUE SHIELD
ID
01
—
T6962
BLUE CROSS
ID
Enumeration date
11/10/2005
Last updated
07/08/2007
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