Provider Demographics
NPI:1003113820
Name:LAKE, DAVID R (ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:LAKE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8917 S 77TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9784
Mailing Address - Country:US
Mailing Address - Phone:414-698-3730
Mailing Address - Fax:
Practice Address - Street 1:8917 S 77TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9784
Practice Address - Country:US
Practice Address - Phone:414-698-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer