Provider Demographics
NPI:1184854929
Name:LAKESIDE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LAKESIDE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:METODIO
Authorized Official - Middle Name:AMAHIT
Authorized Official - Last Name:PAMPLONA
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:302-280-6920
Mailing Address - Street 1:404 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-1741
Mailing Address - Country:US
Mailing Address - Phone:302-280-6920
Mailing Address - Fax:302-280-6921
Practice Address - Street 1:404 E FRONT ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:DE
Practice Address - Zip Code:19956-1741
Practice Address - Country:US
Practice Address - Phone:302-280-6920
Practice Address - Fax:302-280-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2009603216261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1548466550OtherNPI
DE1548494297OtherNPI