Provider Demographics
NPI:1629363064
Name:LAKESHORE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:LAKESHORE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CITOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-362-1848
Mailing Address - Street 1:712 S MILWAUKEE AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3279
Mailing Address - Country:US
Mailing Address - Phone:847-362-1848
Mailing Address - Fax:847-362-3351
Practice Address - Street 1:712 S MILWAUKEE AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3279
Practice Address - Country:US
Practice Address - Phone:847-362-1848
Practice Address - Fax:847-362-3351
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE COUNTY NEUROSURGERY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-14
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy