Provider Demographics
NPI:1073801262
Name:PRO MOTION THERAPY OF LAKE CITY LLC
Entity type:Organization
Organization Name:PRO MOTION THERAPY OF LAKE CITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-947-4184
Mailing Address - Street 1:PO BOX 632670
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2670
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:702-818-5001
Practice Address - Street 1:945 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5746
Practice Address - Country:US
Practice Address - Phone:386-755-3164
Practice Address - Fax:386-755-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty