Healthcare Provider Details

I. General information

NPI: 1578987533
Provider Name (Legal Business Name): MRS. MICHELLE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4573 NORMANDIE PL
LA MESA CA
91942-8502
US

IV. Provider business mailing address

4573 NORMANDIE PL
LA MESA CA
91942-8502
US

V. Phone/Fax

Practice location:
  • Phone: 619-884-4495
  • Fax:
Mailing address:
  • Phone: 619-884-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: