Healthcare Provider Details

I. General information

NPI: 1467607903
Provider Name (Legal Business Name): SARA DAUGHTRY MCCLAIN P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 SW STONEGATE TER SUITE 101
LAKE CITY FL
32024-3457
US

IV. Provider business mailing address

289 SW STONEGATE TER SUITE 101
LAKE CITY FL
32024-3457
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3164
  • Fax: 386-755-3165
Mailing address:
  • Phone: 386-755-3164
  • Fax: 386-755-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number21431
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number35852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: