Healthcare Provider Details

I. General information

NPI: 1619447620
Provider Name (Legal Business Name): CLAYTON CARSON DYKE III PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 VISTA WAY
OCEANSIDE CA
92054-5663
US

IV. Provider business mailing address

3988 SYME DR
CARLSBAD CA
92008-3569
US

V. Phone/Fax

Practice location:
  • Phone: 760-547-2666
  • Fax: 760-547-2673
Mailing address:
  • Phone: 760-613-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: