Provider Demographics
NPI:1003958653
Name:LAKE COUNTRY PHYSICAL THERAPY & SPORTSCARE, PC
Entity Type:Organization
Organization Name:LAKE COUNTRY PHYSICAL THERAPY & SPORTSCARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ZOE
Authorized Official - Middle Name:
Authorized Official - Last Name:FACKELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:585-396-1400
Mailing Address - Street 1:241 PARRISH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1727
Mailing Address - Country:US
Mailing Address - Phone:585-396-1400
Mailing Address - Fax:585-396-3368
Practice Address - Street 1:241 PARRISH ST
Practice Address - Street 2:SUITE A
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1727
Practice Address - Country:US
Practice Address - Phone:585-396-1400
Practice Address - Fax:585-396-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5776378OtherRCIPPAE
NYG0185178590OtherBLUE CHOICE
NY01608671Medicaid
NY=========OtherGHI
NYG0185178590OtherBLUE CHOICE