Provider Demographics
NPI:1659483758
Name:LAKE WORTH PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:LAKE WORTH PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SISON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:561-317-1374
Mailing Address - Street 1:3400 JOG RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2080
Mailing Address - Country:US
Mailing Address - Phone:561-317-1374
Mailing Address - Fax:561-641-3909
Practice Address - Street 1:3400 JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2080
Practice Address - Country:US
Practice Address - Phone:561-317-1374
Practice Address - Fax:561-641-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY905JOtherBLUE CROSS BLUE SHIELD GR
FLY905JOtherBLUE CROSS BLUE SHIELD GR