Provider Demographics
NPI:1912110362
Name:CLEAR PASSAGE THERAPIES
Entity Type:Organization
Organization Name:CLEAR PASSAGE THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-336-1433
Mailing Address - Street 1:4421 NW 39TH AVENUE
Mailing Address - Street 2:STE 2-2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606
Mailing Address - Country:US
Mailing Address - Phone:352-336-1433
Mailing Address - Fax:352-336-9980
Practice Address - Street 1:4421 NW 39TH AVENUE
Practice Address - Street 2:STE 2-2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606
Practice Address - Country:US
Practice Address - Phone:352-336-1433
Practice Address - Fax:352-336-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4923Medicare ID - Type Unspecified