Provider Demographics
NPI:1508078056
Name:LAKESIDE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:LAKESIDE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:V
Authorized Official - Last Name:GOODIER
Authorized Official - Suffix:
Authorized Official - Credentials:R P T
Authorized Official - Phone:479-253-1711
Mailing Address - Street 1:1221 COUNTY ROAD 157
Mailing Address - Street 2:
Mailing Address - City:EUREKA SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72632-9343
Mailing Address - Country:US
Mailing Address - Phone:479-253-1711
Mailing Address - Fax:215-261-0814
Practice Address - Street 1:1221 COUNTY ROAD 157
Practice Address - Street 2:
Practice Address - City:EUREKA SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72632-9343
Practice Address - Country:US
Practice Address - Phone:479-253-1711
Practice Address - Fax:215-261-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty