Provider Demographics
NPI:1942598883
Name:TEAM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:TEAM PHYSICAL THERAPY LLC
Other - Org Name:ENCHANTED LAKE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:K A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:808-262-2292
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 KEOLU DR
Practice Address - Street 2:SUITE 104
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3871
Practice Address - Country:US
Practice Address - Phone:808-262-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty