Provider Demographics
NPI:1588810659
Name:LAKE CITY PHYSICAL THERAPY P A
Entity Type:Organization
Organization Name:LAKE CITY PHYSICAL THERAPY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEREE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DIBIASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-1988
Mailing Address - Street 1:2170 W IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2606
Mailing Address - Country:US
Mailing Address - Phone:208-667-1988
Mailing Address - Fax:208-765-5654
Practice Address - Street 1:12615 E MISSION AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-891-2623
Practice Address - Fax:509-891-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB33065Medicare PIN