1205694148 NPI number — LAKESIDE PHYSICAL THERAPY AND WELLNESS, LLC

Table of content: (NPI 1205694148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205694148 NPI number — LAKESIDE PHYSICAL THERAPY AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE PHYSICAL THERAPY AND WELLNESS, LLC
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:
1205694148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 SUMMIT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07834-2312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-229-9116
Provider Business Mailing Address Fax Number:
973-329-0101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38 RIGHTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07834-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-229-9116
Provider Business Practice Location Address Fax Number:
973-329-0101
Provider Enumeration Date:
03/06/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MONTANA
Authorized Official First Name:
CHRISTY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
973-229-9116

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)





Copyright © 2007-2025 www.npivalidator.com