NPIMap

Organization Active NPI

Walla Walla Physical Therapy Center Aps

  • Physical Therapist
  • Walla Walla, WA
National Provider Identifier
1477574606
Registry record updated Jun 22, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
601 755 670 Issued in WA
Legal business name
WALLA WALLA PHYSICAL THERAPY CENTER APS
Practice address
275 W Tietan St
Walla Walla, WA 99362-4363
Phone
(509) 522-0114
Fax
(509) 522-9868
NPI assigned
Jul 22, 2006
Reactivated
Jun 22, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 22, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael J Clark, PTNPI 1306849955
Title
Physical Therapist/Owner
Phone
(509) 522-0114

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X SINGLE SPECIALTY GROUP 225100000X 601 755 670 WA Primary

Addresses

Primary practice location

275 W Tietan St
Walla Walla, WA 99362-4363

Mailing address

275 W Tietan St
Walla Walla, WA 99362-4363
Phone (509) 522-0114

Other identifiers 7

IdentifierTypeStateIssuer
1306849955OtherWANPI MICHAEL J CLARK PT
650011919OtherWARAILROAD MEDICARE MIKE
8861197OtherWAMEDICARE
8348476MedicaidWA
CD4682OtherWARAILROAD MED GROUP #
7082266MedicaidWA
8462996MedicaidWA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040324001688 WA Part B Supplier - Clinic/Group Practice 6901797190 Receives reassigned benefits from 3 practitioners
Practice locations: Walla Walla, WA

National Provider Directory

National Provider Directory

Locations

275 W Tietan St
Walla Walla, WA 99362
Phone (509) 522-0114

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687392000000",
    "number": "1477574606",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "275 W TIETAN ST",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993624363",
            "telephone_number": "509-522-0114",
            "fax_number": "509-522-9868"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "275 W TIETAN ST",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993624363",
            "telephone_number": "509-522-0114",
            "fax_number": "509-522-9868"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLA WALLA PHYSICAL THERAPY CENTER APS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-22",
        "last_updated": "2023-06-22",
        "certification_date": "2023-06-22",
        "deactivation_date": "2023-06-02",
        "reactivation_date": "2023-06-22",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PHYSICAL THERAPIST/OWNER",
        "authorized_official_telephone_number": "509-522-0114",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": "WA",
            "license": "601 755 670",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI MICHAEL J CLARK PT",
            "identifier": "1306849955",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE MIKE",
            "identifier": "650011919",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "8861197",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8348476",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MED GROUP #",
            "identifier": "CD4682",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7082266",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8462996",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Walla Walla, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.