Provider Demographics
NPI:1871108910
Name:LAKE AREA PHYSICAL THERAPY CRESCENT CITY, INC
Entity type:Organization
Organization Name:LAKE AREA PHYSICAL THERAPY CRESCENT CITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-475-3113
Mailing Address - Street 1:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-1099
Mailing Address - Country:US
Mailing Address - Phone:352-475-3113
Mailing Address - Fax:352-475-5796
Practice Address - Street 1:101 EUCALYPTUS AVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2407
Practice Address - Country:US
Practice Address - Phone:352-475-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE AREA PHYSICAL THERAPY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty