Provider Demographics
NPI:1699840835
Name:LAKEWOOD PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LAKEWOOD PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-676-0145
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 272E
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2334
Practice Address - Country:US
Practice Address - Phone:208-676-1424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH IDAHO FAMILY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-22
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCG9013OtherRAILROAD MEDICARE
ID1378073Medicare Oscar/Certification
4264500001Medicare NSC
ID1639019Medicare Oscar/Certification