Healthcare Provider Details

I. General information

NPI: 1942439294
Provider Name (Legal Business Name): DAVID LACKENBY P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7331 COLLEGE PKWY STE 300
FORT MYERS FL
33907-5524
US

IV. Provider business mailing address

5920 TROPICAL DR
FORT MYERS FL
33919-1729
US

V. Phone/Fax

Practice location:
  • Phone: 239-337-2003
  • Fax: 239-337-3168
Mailing address:
  • Phone: 239-565-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: