Provider Demographics
NPI:1497951594
Name:LAKEVILLE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:LAKEVILLE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GIVINAL
Authorized Official - Last Name:GOUVEIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:508-947-3004
Mailing Address - Street 1:155 MILLENNIUM CIR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347
Mailing Address - Country:US
Mailing Address - Phone:508-947-3004
Mailing Address - Fax:508-923-6008
Practice Address - Street 1:155 MILLENNIUM CIR
Practice Address - Street 2:SUITE 114
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347
Practice Address - Country:US
Practice Address - Phone:508-947-3004
Practice Address - Fax:508-923-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA20786OtherHPHC
MA9739190Medicaid
MAY61391OtherBCBS
MA9739190Medicaid