Provider Demographics
NPI:1316089568
Name:LAKE MARY PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:LAKE MARY PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PIACENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:407-321-6644
Mailing Address - Street 1:820 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5946
Mailing Address - Country:US
Mailing Address - Phone:407-321-6644
Mailing Address - Fax:407-321-7309
Practice Address - Street 1:820 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-5946
Practice Address - Country:US
Practice Address - Phone:407-321-6644
Practice Address - Fax:407-321-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT1410261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY922POtherBCBS PROVIDER NUMBER
FLY922POtherBCBS PROVIDER NUMBER