Provider Demographics
NPI:1871951996
Name:LAKE SHORE PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:LAKE SHORE PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SERPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-731-3583
Mailing Address - Street 1:4277 HEMPSTEAD TPKE
Mailing Address - Street 2:SUITE 209A
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5709
Mailing Address - Country:US
Mailing Address - Phone:516-731-3583
Mailing Address - Fax:516-731-3587
Practice Address - Street 1:700 UNION PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7427
Practice Address - Country:US
Practice Address - Phone:516-731-3583
Practice Address - Fax:516-731-3587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005760-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty