Provider Demographics
NPI:1578563417
Name:LAFREE ORTHOPEDIC & SPORTS PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:LAFREE ORTHOPEDIC & SPORTS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LAFREE
Authorized Official - Suffix:
Authorized Official - Credentials:PT ATC
Authorized Official - Phone:574-941-2200
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004435A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215756OtherANTHEM PROVIDER NUMBER
IN650022299Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IN000000215756OtherANTHEM PROVIDER NUMBER