Healthcare Provider Details

I. General information

NPI: 1336516269
Provider Name (Legal Business Name): CLARENCE R QUAVE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15476B DEDEAUX RD
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

15476B DEDEAUX RD
GULFPORT MS
39503-2637
US

V. Phone/Fax

Practice location:
  • Phone: 228-539-3232
  • Fax: 228-539-3230
Mailing address:
  • Phone: 228-539-3232
  • Fax: 228-539-3230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5443
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: