Provider Demographics
NPI:1386268134
Name:PHYSIO-LAKEVILLE, LLC
Entity type:Organization
Organization Name:PHYSIO-LAKEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:860-605-8783
Mailing Address - Street 1:12 SUGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:FALLS VILLAGE
Mailing Address - State:CT
Mailing Address - Zip Code:06031-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 SUGAR HILL RD
Practice Address - Street 2:
Practice Address - City:FALLS VILLAGE
Practice Address - State:CT
Practice Address - Zip Code:06031-1009
Practice Address - Country:US
Practice Address - Phone:860-605-8783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty