Provider Demographics
NPI:1073801262
Name:PRO MOTION THERAPY OF LAKE CITY LLC
Entity Type:Organization
Organization Name:PRO MOTION THERAPY OF LAKE CITY LLC
Other - Org Name:FYZICAL THERAPY & BALANCE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-870-7090
Mailing Address - Street 1:9070 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8935
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:702-818-5001
Practice Address - Street 1:945 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5746
Practice Address - Country:US
Practice Address - Phone:386-755-3164
Practice Address - Fax:386-755-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X, 261QP2000X
FL5079235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty