Individual
ETHAN LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT
Contact information
Practice address
80 HIGHWAY 304, CALERA, AL 35040-5551
(205) 668-6900
(205) 668-2677
Mailing address
1200 CORPORATE DR STE 400, HOOVER, AL 35242-5424
(423) 238-7217
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
1-1177
AL
225100000X
Physical Therapist
Primary
PTH10621
AL
Other
Enumeration date
09/12/2021
Last updated
11/12/2021
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