Provider Demographics
NPI:1538417233
Name:LAKE HEALTH & REHAB, LLC
Entity type:Organization
Organization Name:LAKE HEALTH & REHAB, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:STIMAC
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-756-1128
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-309-2579
Practice Address - Street 1:306 STONER LOOP STE 3
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922-8601
Practice Address - Country:US
Practice Address - Phone:406-844-0744
Practice Address - Fax:406-844-0759
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTH & REHAB SOLUTIONS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-28
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MT1614332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011003011OtherMEDICARE #