Healthcare Provider Details

I. General information

NPI: 1720403413
Provider Name (Legal Business Name): BAY AREA SPINE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 W OLIVE AVE STE B&D
MERCED CA
95348-1959
US

IV. Provider business mailing address

1170 W OLIVE AVE STE B&D
MERCED CA
95348-1959
US

V. Phone/Fax

Practice location:
  • Phone: 209-276-2200
  • Fax: 209-276-2202
Mailing address:
  • Phone: 209-276-2200
  • Fax: 209-276-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA76201
License Number StateCA

VIII. Authorized Official

Name: MICHAEL W CLUCK
Title or Position: OWNER
Credential: MD
Phone: 408-295-2200