Provider Demographics
NPI:1255646709
Name:GREAT LAKES PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JON
Authorized Official - Last Name:HALLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:712-320-2722
Mailing Address - Street 1:3301 BERGQUIST AVEUE
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-7268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 BERGQUIST AVE
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-7268
Practice Address - Country:US
Practice Address - Phone:712-336-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00807261QP2000X
IA01261261QP2000X
IA01929261QP2000X
IA03253261QP2000X
IA01681261QR0400X
IA055168261QR0401X
IA00868261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)