Provider Demographics
NPI:1386988970
Name:LAKEPORT PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:LAKEPORT PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-263-5210
Mailing Address - Street 1:381 LAKEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5412
Mailing Address - Country:US
Mailing Address - Phone:707-263-5210
Mailing Address - Fax:707-263-8045
Practice Address - Street 1:381 LAKEPORT BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5412
Practice Address - Country:US
Practice Address - Phone:707-263-5210
Practice Address - Fax:707-263-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty