Provider Demographics
NPI:1346442449
Name:COURT CLUB PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:COURT CLUB PHYSICAL THERAPY, LLC
Other - Org Name:PHYSICAL THERAPY @ THE PACIFIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KLIPHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-735-2014
Mailing Address - Street 1:1350 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1355
Mailing Address - Country:US
Mailing Address - Phone:509-735-2014
Mailing Address - Fax:509-735-3980
Practice Address - Street 1:1350 N GRANT ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1355
Practice Address - Country:US
Practice Address - Phone:509-735-2014
Practice Address - Fax:509-735-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7119324Medicaid
WA7119324Medicaid