Provider Demographics
NPI:1588809461
Name:LAKEWAY PHYSICAL THERAPY OUTPATIENT, PLLC
Entity Type:Organization
Organization Name:LAKEWAY PHYSICAL THERAPY OUTPATIENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSELITO
Authorized Official - Middle Name:
Authorized Official - Last Name:PASAOL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:931-232-4555
Mailing Address - Street 1:75 CASTLETON CV
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-5942
Mailing Address - Country:US
Mailing Address - Phone:931-232-4555
Mailing Address - Fax:
Practice Address - Street 1:402-C CHURCH ST.
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058
Practice Address - Country:US
Practice Address - Phone:931-232-4555
Practice Address - Fax:931-232-4599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0590012261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523011Medicaid
TN103G704752Medicare PIN