Provider Demographics
NPI:1538358585
Name:PRO MOTION THERAPY OF LAKE CITY LLC
Entity type:Organization
Organization Name:PRO MOTION THERAPY OF LAKE CITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-947-4184
Mailing Address - Street 1:PO BOX 632670
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2670
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:702-818-5001
Practice Address - Street 1:4423 NW 6TH PL STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6116
Practice Address - Country:US
Practice Address - Phone:352-325-2276
Practice Address - Fax:352-877-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6083580001OtherPTAN
FL6083580001OtherPTAN