Healthcare Provider Details

I. General information

NPI: 1427424878
Provider Name (Legal Business Name): CHELSEA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 MISSION BLVD SUITE 101
SAN DIEGO CA
92109-8028
US

IV. Provider business mailing address

4085 SEQUOIA ST
SAN DIEGO CA
92109-6159
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-3597
  • Fax:
Mailing address:
  • Phone: 207-756-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: