Healthcare Provider Details

I. General information

NPI: 1184854929
Provider Name (Legal Business Name): LAKESIDE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E FRONT ST
LAUREL DE
19956-1741
US

IV. Provider business mailing address

404 E FRONT ST
LAUREL DE
19956-1741
US

V. Phone/Fax

Practice location:
  • Phone: 302-280-6920
  • Fax: 302-280-6921
Mailing address:
  • Phone: 302-280-6920
  • Fax: 302-280-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2009603216
License Number StateDE

VIII. Authorized Official

Name: MR. METODIO AMAHIT PAMPLONA JR.
Title or Position: OWNER
Credential: P.T.
Phone: 302-280-6920