1164429163 NPI number — LAKE SUPERIOR PHYSICAL THERAPY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164429163 NPI number — LAKE SUPERIOR PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SUPERIOR 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:
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:
1164429163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 N CENTRAL AVE
Provider Second Line Business Mailing Address:
14B
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55807-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-625-6300
Provider Business Mailing Address Fax Number:
218-724-6700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
14B
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55807-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-625-6300
Provider Business Practice Location Address Fax Number:
218-724-6700
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WALLEN
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
218-625-6300

Provider Taxonomy Codes

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

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





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