Healthcare Provider Details

I. General information

NPI: 1629363064
Provider Name (Legal Business Name): LAKESHORE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S MILWAUKEE AVE LOWER LEVEL
LIBERTYVILLE IL
60048-3279
US

IV. Provider business mailing address

712 S MILWAUKEE AVE LOWER LEVEL
LIBERTYVILLE IL
60048-3279
US

V. Phone/Fax

Practice location:
  • Phone: 847-362-1848
  • Fax: 847-362-3351
Mailing address:
  • Phone: 847-362-1848
  • Fax: 847-362-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: JONATHAN S CITOW
Title or Position: OWNER
Credential: MD
Phone: 847-362-1848