Provider Demographics
NPI:1376604389
Name:LAKESHORE REHABILITATION CENTER PC
Entity Type:Organization
Organization Name:LAKESHORE REHABILITATION CENTER PC
Other - Org Name:WEST MICHIGAN SPORTS MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-728-4102
Mailing Address - Street 1:137 E LAKETON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5507
Mailing Address - Country:US
Mailing Address - Phone:231-728-4102
Mailing Address - Fax:231-722-0800
Practice Address - Street 1:137 E LAKETON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5507
Practice Address - Country:US
Practice Address - Phone:231-728-4102
Practice Address - Fax:231-722-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N23350Medicare ID - Type Unspecified