Provider Demographics
NPI:1083896674
Name:LAKELAND PHYSICAL THERAPY AND SPORTS INJURIES P.A.
Entity Type:Organization
Organization Name:LAKELAND PHYSICAL THERAPY AND SPORTS INJURIES P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-765-4185
Mailing Address - Street 1:16768 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16768 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8715
Practice Address - Country:US
Practice Address - Phone:208-687-9195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652482Medicare PIN