Healthcare Provider Details

I. General information

NPI: 1053780395
Provider Name (Legal Business Name): ANDREW CLENDENEN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 SEVERIN DR
LA MESA CA
91942-3806
US

IV. Provider business mailing address

1643 6TH AVE APT 209
SAN DIEGO CA
92101-2758
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-2606
  • Fax: 619-464-0900
Mailing address:
  • Phone: 563-451-6944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: