Provider Demographics
NPI:1376682518
Name:LAKE AREA PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:LAKE AREA PHYSICAL THERAPY INC
Other - Org Name:LAKE AREA PHYSICAL THERAPY & AQUATICS INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:352-475-3113
Mailing Address - Street 1:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-1099
Mailing Address - Country:US
Mailing Address - Phone:352-475-3113
Mailing Address - Fax:352-475-5796
Practice Address - Street 1:25727 NE STATE RD 26
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-1099
Practice Address - Country:US
Practice Address - Phone:352-475-3113
Practice Address - Fax:352-475-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880554700Medicaid
FLR8JOtherBLUE CROSS PROV#
FL5941306OtherAETNA PROV#
FL103999OtherAVMED PROVIDER #
FL106944OtherMEDICARE
FLR8JOtherBLUE CROSS PROV#