MEDICARE: CLEAR LAKE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1083328785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR LAKE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	PO BOX 147
Second Line	:
City	:	CLEAR LAKE
State	:	WI
Zip	:	54005-8905
Country	:	US
Telephone Number	:	715-263-4103
Fax Number	:

Provider Business Practice Location Address
First Line	:	224 RIVER AVE S
Second Line	:
City	:	PRAIRIE FARM
State	:	WI
Zip	:	54762-9786
Country	:	US
Telephone Number	:	715-263-4103
Fax Number	:

Authorized Official
Title or Position	:	OWEN
Name	:	EMILY J MONSON
Credential	:	PT
Telephone Number	:	715-263-4103

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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