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General NPI Number Information
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NPI Number | 1245295385
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Entity Type | Organization
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Legal Business Name | CLEAR LAKE PHYSICAL THERAPY INC
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 12/01/2009
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Provider Practice Location Address
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Address Line | 1173 11TH STREET
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City | LAKEPORT
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State | CA
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Zip | 95453
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Country | US
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Telephone | 707-263-1295
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Fax | 707-263-1295
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Provider Business Mailing Address
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Address Line | 1173 11TH STREET
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City | LAKEPORT
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State | CA
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Zip | 95453
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Country | US
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Telephone | 707-263-1295
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Fax | 707-263-1295
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Authorized Official
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Title or Position | OWNER
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Name | LAWRENCE HOSMER HURST
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Credential | PT
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Telephone | 707-263-1295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT17230
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License Number State | CA
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