Healthcare Provider Details

I. General information

NPI: 1699840835
Provider Name (Legal Business Name): LAKEWOOD PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LINCOLN WAY
COEUR D ALENE ID
83814-2334
US

IV. Provider business mailing address

700 W IRONWOOD DR SUITE 272E
COEUR D ALENE ID
83814-2656
US

V. Phone/Fax

Practice location:
  • Phone: 208-676-1424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ERIC KOELSCH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-676-0145