Provider Demographics
NPI:1316271679
Name:LACKLAND, KURTIS (MPT)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:
Last Name:LACKLAND
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HOSPITAL DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2535
Mailing Address - Country:US
Mailing Address - Phone:573-642-8541
Mailing Address - Fax:573-642-8500
Practice Address - Street 1:3075 TOWER RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2536
Practice Address - Country:US
Practice Address - Phone:706-507-3794
Practice Address - Fax:706-507-3681
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009028456225100000X
GAPT011452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist