Healthcare Provider Details

I. General information

NPI: 1275508400
Provider Name (Legal Business Name): JAMES BAUMAN CLOVER JR. MED, ATC, PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 MAGNOLIA AVE
RIVERSIDE CA
92501-4136
US

IV. Provider business mailing address

3721 BEECHWOOD PL
RIVERSIDE CA
92506-1217
US

V. Phone/Fax

Practice location:
  • Phone: 951-274-3484
  • Fax: 951-274-3599
Mailing address:
  • Phone: 951-274-3484
  • Fax: 951-274-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07802652
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number790198
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: