Provider Demographics
NPI:1477574606
Name:WALLA WALLA PHYSICAL THERAPY CENTER APS
Entity Type:Organization
Organization Name:WALLA WALLA PHYSICAL THERAPY CENTER APS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-522-0114
Mailing Address - Street 1:275 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4363
Mailing Address - Country:US
Mailing Address - Phone:509-522-0114
Mailing Address - Fax:509-522-9868
Practice Address - Street 1:275 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4363
Practice Address - Country:US
Practice Address - Phone:509-522-0114
Practice Address - Fax:509-522-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2023-06-22
Deactivation Date:2023-06-02
Deactivation Code:
Reactivation Date:2023-06-22
Provider Licenses
StateLicense IDTaxonomies
WA601 755 670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306849955OtherNPI MICHAEL J CLARK PT
WA650011919OtherRAILROAD MEDICARE MIKE
WA8861197OtherMEDICARE
WA8348476Medicaid
WACD4682OtherRAILROAD MED GROUP #
WA7082266Medicaid
WA8462996Medicaid
WACD4682OtherRAILROAD MED GROUP #
WAGAB08226Medicare ID - Type UnspecifiedMICHAEL J CLARK PT