Provider Demographics
NPI:1174830202
Name:COUNTRY CLUB PT PA
Entity Type:Organization
Organization Name:COUNTRY CLUB PT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:561-632-2160
Mailing Address - Street 1:513 US HIGHWAY 1 STE 216
Mailing Address - Street 2:
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-4905
Mailing Address - Country:US
Mailing Address - Phone:561-632-2160
Mailing Address - Fax:561-842-6458
Practice Address - Street 1:13200 EASTPOINTE WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33418-1418
Practice Address - Country:US
Practice Address - Phone:561-632-2160
Practice Address - Fax:561-842-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty