Provider Demographics
NPI:1023183142
Name:LAKESIDE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LAKESIDE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MNAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-891-0658
Mailing Address - Street 1:PO BOX 3115
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-3115
Mailing Address - Country:US
Mailing Address - Phone:208-765-0805
Mailing Address - Fax:
Practice Address - Street 1:1512 N VERCLER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1087
Practice Address - Country:US
Practice Address - Phone:509-891-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7094345Medicaid
WA7094345Medicaid