Basic Information
| Provider Information | |||||||||
| NPI: | 1174576706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACLAIR | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | DPT, CSCS, NSCA-CPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | UNION GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531821303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628789602 | ||||||||
| FaxNumber: | 2628789609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | UNION GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531821303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628789602 | ||||||||
| FaxNumber: | 2628789609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9917024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40384500 | 05 | WI | MEDICAID |