MEDICARE: CAROLINE MCCLEMONS M.P.T.

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	225100000X	Physical Therapist	PT19272	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FJ9518	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1982655742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINE MCCLEMONS M.P.T.

Provider Business Mailing Address
First Line	:	2041 NEWCASTLE AVE
Second Line	:
City	:	CARDIFF
State	:	CA
Zip	:	92007-1762
Country	:	US
Telephone Number	:	760-230-5432
Fax Number	:

Provider Business Practice Location Address
First Line	:	2041 NEWCASTLE AVE
Second Line	:
City	:	CARDIFF
State	:	CA
Zip	:	92007-1762
Country	:	US
Telephone Number	:	760-230-5432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	02/14/2012

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