1033460936 NPI number — LAKEVIEW NEUROREHAB CENTER MIDWEST, INC.

Table of content: ANNA DARIA JOHNSTON PT, DPT (NPI 1164197604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033460936 NPI number — LAKEVIEW NEUROREHAB CENTER MIDWEST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW NEUROREHAB CENTER MIDWEST, 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:
1033460936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 SHARP RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53185-5214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-534-7297
Provider Business Mailing Address Fax Number:
262-534-7257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 SHARP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53185-5214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-534-7297
Provider Business Practice Location Address Fax Number:
262-534-7257
Provider Enumeration Date:
10/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVARES
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
COO & ADMINISTRATOR
Authorized Official Telephone Number:
262-534-7297

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6604929 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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