Provider Demographics
NPI:1154583292
Name:LAKE REGION THERAPY SERVICES INC
Entity type:Organization
Organization Name:LAKE REGION THERAPY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:218-844-5555
Mailing Address - Street 1:803 ROOSEVELT AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3744
Mailing Address - Country:US
Mailing Address - Phone:218-844-5555
Mailing Address - Fax:218-844-6057
Practice Address - Street 1:803 ROOSEVELT AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3744
Practice Address - Country:US
Practice Address - Phone:218-844-5555
Practice Address - Fax:218-844-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9552335261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation