Provider Demographics
NPI:1487811246
Name:LANE, TOM III (ATC)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:LANE
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 EDGEWOOD DRIVE
Mailing Address - Street 2:APARTMENT 4B
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-302-1870
Mailing Address - Fax:
Practice Address - Street 1:1475 EDGEWOO DRIVE
Practice Address - Street 2:APT 4B
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805
Practice Address - Country:US
Practice Address - Phone:419-302-1870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-7702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer