Provider Demographics
NPI:1659635357
Name:LAKEVILLE PHYSICAL THERAPY & ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:LAKEVILLE PHYSICAL THERAPY & ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:ACUPUNCTURE
Authorized Official - Phone:516-263-8190
Mailing Address - Street 1:2035 LAKEVILLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1600
Mailing Address - Country:US
Mailing Address - Phone:516-263-8190
Mailing Address - Fax:516-492-3299
Practice Address - Street 1:2035 LAKEVILLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1600
Practice Address - Country:US
Practice Address - Phone:516-263-8190
Practice Address - Fax:516-492-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003113302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization