Healthcare Provider Details

I. General information

NPI: 1952521411
Provider Name (Legal Business Name): LAKE CITY PHYSICAL THERAPY P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8238 N GOVERNMENT WAY
HAYDEN ID
83835-5034
US

IV. Provider business mailing address

PO BOX 1180
HAYDEN ID
83835-1180
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-2100
  • Fax:
Mailing address:
  • Phone: 208-966-4176
  • Fax: 208-765-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberRPT629
License Number StateID

VIII. Authorized Official

Name: SHEREE LYNN DIBIASE
Title or Position: OWNER
Credential:
Phone: 208-667-1988