Provider Demographics
NPI:1851487581
Name:LAKE COUNTY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LAKE COUNTY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZUBIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TANTRA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-201-7612
Mailing Address - Street 1:511 E HAWLEY ST
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-2419
Mailing Address - Country:US
Mailing Address - Phone:847-543-7604
Mailing Address - Fax:847-543-7605
Practice Address - Street 1:511 E HAWLEY ST
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2419
Practice Address - Country:US
Practice Address - Phone:847-543-7604
Practice Address - Fax:847-543-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-006952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04922918OtherBLUE CROSS BLUE SHIELD PROVIDER ID
IL574300Medicare PIN
IL552360Medicare PIN