=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588845804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKES AREA PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 04/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 GENEVA PKWY N SUITE 3
-----------------------------------------------------
City | LAKE GENEVA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53147-5701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-248-9902
-----------------------------------------------------
Fax | 262-248-9419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 GENEVA PKWY N SUITE 3
-----------------------------------------------------
City | LAKE GENEVA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53147-5701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-248-9902
-----------------------------------------------------
Fax | 262-248-9419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIS / OWNER
-----------------------------------------------------
Name | JOHN R VAN SUSTEREN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-248-9902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 4467024
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------