Healthcare Provider Details

I. General information

NPI: 1871108910
Provider Name (Legal Business Name): LAKE AREA PHYSICAL THERAPY CRESCENT CITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EUCALYPTUS AVE
CRESCENT CITY FL
32112-2407
US

IV. Provider business mailing address

PO BOX 1099
MELROSE FL
32666-1099
US

V. Phone/Fax

Practice location:
  • Phone: 352-475-3113
  • Fax:
Mailing address:
  • Phone: 352-475-3113
  • Fax: 352-475-5796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURA HODGES
Title or Position: OWNER
Credential:
Phone: 352-475-3113