Healthcare Provider Details

I. General information

NPI: 1396984670
Provider Name (Legal Business Name): LAKESIDE PHYSICAL THERAPY & FITNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 WHITE MOUNTAIN HWY
TAMWORTH NH
03886-4625
US

IV. Provider business mailing address

685 WHITE MOUNTAIN HWY
TAMWORTH NH
03886-4638
US

V. Phone/Fax

Practice location:
  • Phone: 603-323-2089
  • Fax: 603-323-2097
Mailing address:
  • Phone: 603-323-2089
  • Fax: 603-323-2097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1953
License Number StateNH

VIII. Authorized Official

Name: MR. JACK TOMASZ HADAM
Title or Position: DPT/ OWNER
Credential: DPT
Phone: 603-323-2089