MEDICARE: LAKES PT PLLC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1891420642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES PT PLLC

Provider Business Mailing Address
First Line	:	3656 JOHNSON AVE APT 6G
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1616
Country	:	US
Telephone Number	:	760-819-1921
Fax Number	:	929-810-3278

Provider Business Practice Location Address
First Line	:	3265 JOHNSON AVE STE 211
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3539
Country	:	US
Telephone Number	:	760-819-1921
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	BRANDO LYDELL LAKES
Credential	:
Telephone Number	:	929-755-2682

Provider Enumeration Date	:	07/17/2022
Last Update Date	:	03/29/2026

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