Healthcare Provider Details

I. General information

NPI: 1659967461
Provider Name (Legal Business Name): ANTHONY MCCLOUD JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N BRENT ST
VENTURA CA
93003-2809
US

IV. Provider business mailing address

10655 LEMON AVE APT 3905
RANCHO CUCAMONGA CA
91737-6979
US

V. Phone/Fax

Practice location:
  • Phone: 805-948-5672
  • Fax:
Mailing address:
  • Phone: 424-903-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: