Provider Demographics
NPI:1477502912
Name:CLEAR LAKE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:CLEAR LAKE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:HOSMER
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-263-1295
Mailing Address - Street 1:14855 OLYMPIC DR
Mailing Address - Street 2:PO BOX 3288
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9522
Mailing Address - Country:US
Mailing Address - Phone:707-994-7248
Mailing Address - Fax:707-994-7248
Practice Address - Street 1:14855 OLYMPIC DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9522
Practice Address - Country:US
Practice Address - Phone:707-994-7248
Practice Address - Fax:707-994-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001040Medicaid
CAZZZ19896ZMedicare PIN
CA4524620001Medicare NSC