MEDICARE: PRO MOTION THERAPY OF LAKE CITY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1538358585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO MOTION THERAPY OF LAKE CITY LLC

Provider Business Mailing Address
First Line	:	PO BOX 632670
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-2670
Country	:	US
Telephone Number	:	702-818-5000
Fax Number	:	702-818-5001

Provider Business Practice Location Address
First Line	:	4423 NW 6TH PL STE C
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32607-6116
Country	:	US
Telephone Number	:	352-325-2276
Fax Number	:	352-877-4580

Authorized Official
Title or Position	:	CHIEF CLINICAL OFFICER
Name	:	ERIC ELDON DOUGLASS
Credential	:
Telephone Number	:	239-947-4184

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	08/20/2025

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