Provider Demographics
NPI:1164690780
Name:LAKE DOW PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:LAKE DOW PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEDDING
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CEAS
Authorized Official - Phone:678-583-6345
Mailing Address - Street 1:42 OLD JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-3029
Mailing Address - Country:US
Mailing Address - Phone:678-583-6345
Mailing Address - Fax:678-583-6346
Practice Address - Street 1:42 OLD JACKSON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-3029
Practice Address - Country:US
Practice Address - Phone:678-583-6345
Practice Address - Fax:678-583-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT006775OtherPT LISCENSE