Provider Demographics
NPI:1548374473
Name:LB PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:LB PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUYCKX
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:269-556-0881
Mailing Address - Street 1:2746 SANCTUARY DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-8313
Mailing Address - Country:US
Mailing Address - Phone:269-408-1990
Mailing Address - Fax:269-408-1993
Practice Address - Street 1:2800 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3317
Practice Address - Country:US
Practice Address - Phone:269-408-1944
Practice Address - Fax:269-408-1946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007604225100000X
MI5501008773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650A157160OtherBLUE CROSS BLUE SHIELD
MIN69330001Medicare ID - Type UnspecifiedDR. LUYCKX INDIVIDUAL
MI650A157160OtherBLUE CROSS BLUE SHIELD
MI0N69330Medicare ID - Type UnspecifiedMEDICARE GROUP