1376682518 NPI number — LAKE AREA PHYSICAL THERAPY INC

Table of content: (NPI 1376682518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376682518 NPI number — LAKE AREA PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE AREA PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376682518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1099
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELROSE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32666-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-475-3113
Provider Business Mailing Address Fax Number:
352-475-5796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25727 NE STATE RD 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELROSE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32666-1099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-475-3113
Provider Business Practice Location Address Fax Number:
352-475-5796
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HODGES
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-475-3113

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 880554700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: R8J . This is a "BLUE CROSS PROV#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5941306 . This is a "AETNA PROV#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103999 . This is a "AVMED PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 106944 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 880554700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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