Provider Demographics
NPI:1073169777
Name:LAKEFRONT PT LLC
Entity Type:Organization
Organization Name:LAKEFRONT PT LLC
Other - Org Name:LAKEFRONT PT LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HITCHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:765-744-6354
Mailing Address - Street 1:201 N WESTSHORE DR APT 1602
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7262
Mailing Address - Country:US
Mailing Address - Phone:765-744-6354
Mailing Address - Fax:
Practice Address - Street 1:71 S WACKER DR # 200A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-4637
Practice Address - Country:US
Practice Address - Phone:765-744-6354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-18
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty