Provider Demographics
NPI:1730764499
Name:LASER FOCUS PEDIATRIC THERAPY CENTER, LLC
Entity type:Organization
Organization Name:LASER FOCUS PEDIATRIC THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-834-5252
Mailing Address - Street 1:3409 NW 9TH AVE STE 1104
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5945
Mailing Address - Country:US
Mailing Address - Phone:954-835-5252
Mailing Address - Fax:954-533-3898
Practice Address - Street 1:3409 NW 9TH AVE STE 1104
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5945
Practice Address - Country:US
Practice Address - Phone:954-835-5252
Practice Address - Fax:954-533-3898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16267Medicaid