Provider Demographics
NPI:1487666533
Name:KLUCK THERAPY CENTER INC
Entity Type:Organization
Organization Name:KLUCK THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPC
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-289-0801
Mailing Address - Street 1:224 BRIAR CLIFF ST SW
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065
Mailing Address - Country:US
Mailing Address - Phone:815-765-0200
Mailing Address - Fax:815-765-1920
Practice Address - Street 1:810 SOUTH MAPLE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-753-5400
Practice Address - Fax:605-753-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD69225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5832233Medicaid
SD0040135OtherBLUE CROSS BLUE SHIELD SD
SD0069OtherDAKOTA CARE
S42107Medicare ID - Type Unspecified