Healthcare Provider Details

I. General information

NPI: 1902612708
Provider Name (Legal Business Name): CLAY ANTHONY CUNEO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

537 SANTA ROSA CT
MANTECA CA
95336-3428
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 209-898-5824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number307324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: