Healthcare Provider Details

I. General information

NPI: 1760904478
Provider Name (Legal Business Name): MR. JOHN MARTIN LACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 LAKE UNDERHILL RD STE 345
ORLANDO FL
32822-8209
US

IV. Provider business mailing address

10609 SPRING BUCK TRL
ORLANDO FL
32825-8522
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-8626
  • Fax:
Mailing address:
  • Phone: 407-303-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6730
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: