Provider Demographics
NPI:1437159373
Name:LAFREE, JOHN EDWARD (PT ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:LAFREE
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8083
Mailing Address - Country:US
Mailing Address - Phone:574-941-2200
Mailing Address - Fax:574-941-2206
Practice Address - Street 1:2934 MILLER DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8083
Practice Address - Country:US
Practice Address - Phone:574-941-2200
Practice Address - Fax:574-941-2206
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004435A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215756OtherANTHEM PROVIDER NUMBER
IN650022299Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
IN228690BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER