Provider Demographics
NPI:1114101243
Name:CLEAR PASSAGE THERAPIES ORANGE COUNTY, INC.
Entity Type:Organization
Organization Name:CLEAR PASSAGE THERAPIES ORANGE COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-336-1433
Mailing Address - Street 1:3600 NW 43RD ST STE A1
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-8138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18271 MCDURMOTT STREET
Practice Address - Street 2:STE J
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614
Practice Address - Country:US
Practice Address - Phone:866-222-9437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEAR PASSAGE THERAPIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19535Medicare PIN