# COUNTRY CLUB PT PA

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1578928420
- **Authorized official:** LISA CORN (OFFICE MANAGER)
- **Authorized official phone:** (941) 451-6689

## Contact information

- **Practice address:** 1331 WHISPERING LN, VENICE, FL 34285-6449
- **Practice address phone:** (941) 451-6689
- **Mailing address:** 1331 WHISPERING LN, VENICE, FL 34285-6449
- **Mailing address phone:** (941) 451-6689

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2251G0304X | Geriatric Physical Therapist | PT21464 | FL | Yes |

## Other

- **Enumeration date:** 12/19/2015
- **Last updated:** 12/19/2015