Provider Demographics
NPI:1891420642
Name:LAKES PT PLLC
Entity Type:Organization
Organization Name:LAKES PT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDO
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAKES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:760-819-1921
Mailing Address - Street 1:3656 JOHNSON AVE APT 6G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1616
Mailing Address - Country:US
Mailing Address - Phone:760-819-1921
Mailing Address - Fax:929-810-3278
Practice Address - Street 1:3656 JOHNSON AVE APT 6G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1616
Practice Address - Country:US
Practice Address - Phone:760-819-1921
Practice Address - Fax:929-810-3278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-17
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy