Provider Demographics
NPI:1669749396
Name:PARK LAKE PHYSICAL MEDICINE, LLC
Entity type:Organization
Organization Name:PARK LAKE PHYSICAL MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-839-1045
Mailing Address - Street 1:2206 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4912
Mailing Address - Country:US
Mailing Address - Phone:407-839-1045
Mailing Address - Fax:407-839-1044
Practice Address - Street 1:2206 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4912
Practice Address - Country:US
Practice Address - Phone:407-839-1045
Practice Address - Fax:407-839-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6694190001OtherDMERC