Healthcare Provider Details

I. General information

NPI: 1073801262
Provider Name (Legal Business Name): PRO MOTION THERAPY OF LAKE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 SW MAIN BLVD
LAKE CITY FL
32025-5746
US

IV. Provider business mailing address

PO BOX 632670
CINCINNATI OH
45263-2670
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3164
  • Fax: 386-755-3165
Mailing address:
  • Phone: 702-818-5000
  • Fax: 702-818-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC ELDON DOUGLASS
Title or Position: CHIEF CLINICAL OFFICER
Credential:
Phone: 239-947-4184