Provider Demographics
NPI:1386957843
Name:LAKESIDE PHYSICAL THERAPY & FITNESS CENTER
Entity type:Organization
Organization Name:LAKESIDE PHYSICAL THERAPY & FITNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:TOMASZ
Authorized Official - Last Name:HADAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:603-323-2089
Mailing Address - Street 1:685 WHITE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03886-4638
Mailing Address - Country:US
Mailing Address - Phone:603-323-2089
Mailing Address - Fax:603-323-2097
Practice Address - Street 1:685 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:TAMWORTH
Practice Address - State:NH
Practice Address - Zip Code:03886-4638
Practice Address - Country:US
Practice Address - Phone:603-323-2089
Practice Address - Fax:603-323-2097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty