NPIMap

Organization Active NPI

Lakeside Orthopedic Institute, LLC

  • Physical Therapist
  • Lake Havasu City, AZ
National Provider Identifier
1962636050
Registry record updated May 5, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
2641 Issued in AZ
Legal business name
LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Practice address
1979 McCulloch Blvd N
Suite 101
Lake Havasu City, AZ 86403-0953
Phone
(928) 855-4842
Fax
(928) 855-7452
NPI assigned
May 5, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Wesley James Johnson, M.D.
Title
President
Phone
92885455555

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 225100000X 2641 AZ Primary
Physical TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 225100000X 8192 AZ
Physical TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 225100000X 6762 AZ

Addresses

Primary practice location

1979 McCulloch Blvd N
Suite 101
Lake Havasu City, AZ 86403-0953

Mailing address

25 Riviera Blvd
Lake Havasu City, AZ 86403-5694
Phone (928) 854-5555

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060918000307 AZ Part B Supplier - Clinic/Group Practice 1052316445 Receives reassigned benefits from 14 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Quartzite, AZ; Lake Havasu City, AZ; Bullhead City, AZ

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

25 Riviera Blvd
Lk Havasu Cty, AZ 86403
Phone (928) 505-7246

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1241481600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1241481600000",
    "number": "1962636050",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25 RIVIERA BLVD",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864035694",
            "telephone_number": "928-854-5555",
            "fax_number": "928-854-5573"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1979 MCCULLOCH BLVD N",
            "address_2": "SUITE 101",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864030953",
            "telephone_number": "928-855-4842",
            "fax_number": "928-855-7452"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE ORTHOPEDIC INSTITUTE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-05",
        "last_updated": "2009-05-05",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "WESLEY",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "92885455555",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "AZ",
            "license": "2641",
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "AZ",
            "license": "8192",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "AZ",
            "license": "6762",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Havasu City, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.