NPIMap

Organization Active NPI

Team Physical Therapy LLC

Doing business as Enchanted Lake Physical Therapy

  • Physical Therapist
  • Kailua, HI
National Provider Identifier
1942598883
Registry record updated Mar 11, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
TEAM PHYSICAL THERAPY LLC
Doing business as
Enchanted Lake Physical Therapy
Practice address
1090 Keolu Dr
Suite 104
Kailua, HI 96734-3871
Phone
(808) 262-2292
NPI assigned
Jul 13, 2011
Last updated
Mar 11, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2016

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

Authorized official

Name
Mr. Todd K. a. Clark, MSPTNPI 1790850758
Title
Co-Owner/Physical Therapist
Phone
(808) 262-2292

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 Primary

Addresses

Primary practice location

1090 Keolu Dr
Suite 104
Kailua, HI 96734-3871

Mailing address

PO Box 1440
Kailua, HI 96734-1440

Other names 1

  • Enchanted Lake Physical Therapy Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120504000244 HI Part B Supplier - Physical/Occupational Therapy Group in Private Practice 7416119698 Receives reassigned benefits from 5 practitioners
Practice locations: Kailua, HI

National Provider Directory

National Provider Directory

Locations

1090 Keolu Dr
Ste 104
Kailua, HI 96734
Phone (808) 262-2292

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1310515200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1457654400000",
    "number": "1942598883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1440",
            "city": "KAILUA",
            "state": "HI",
            "postal_code": "967341440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1090 KEOLU DR",
            "address_2": "SUITE 104",
            "city": "KAILUA",
            "state": "HI",
            "postal_code": "967343871",
            "telephone_number": "808-262-2292"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TEAM PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-13",
        "last_updated": "2016-03-11",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "TODD",
        "authorized_official_middle_name": "K. A.",
        "authorized_official_title_or_position": "CO-OWNER/PHYSICAL THERAPIST",
        "authorized_official_telephone_number": "808-262-2292",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MSPT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Enchanted Lake Physical Therapy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kailua, HI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2016; 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.