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NPI Code Detail

MEDICARE: MACKENZIE LAKE COLLETON DPT

MEDICARE: MACKENZIE LAKE COLLETON DPT
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
1225100000XPhysical Therapist2305214334VA

General Provider Information

NPI Number : 1811888647
Entity Type Code : Individual
Provider Name (Legal Business Name) : MACKENZIE LAKE COLLETON DPT
Provider Business Mailing Address
First Line : 1901 LIBBIE AVE
Second Line :
City : RICHMOND
State : VA
Zip : 23226-1808
Country : US
Telephone Number : 804-281-2501
Fax Number :
Provider Business Practice Location Address
First Line : 1901 LIBBIE AVE
Second Line :
City : RICHMOND
State : VA
Zip : 23226-1808
Country : US
Telephone Number : 804-281-3501
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/10/2025
Last Update Date : 07/10/2025

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Directions to “ MACKENZIE LAKE COLLETON DPT” Practice Location

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