Provider Demographics
NPI:1588845804
Name:LAKES AREA PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LAKES AREA PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIS / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAN SUSTEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-248-9902
Mailing Address - Street 1:800 GENEVA PKWY N
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-5701
Mailing Address - Country:US
Mailing Address - Phone:262-248-9902
Mailing Address - Fax:262-248-9419
Practice Address - Street 1:800 GENEVA PKWY N
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-5701
Practice Address - Country:US
Practice Address - Phone:262-248-9902
Practice Address - Fax:262-248-9419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4467024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000086657Medicare PIN