Healthcare Provider Details

I. General information

NPI: 1043809932
Provider Name (Legal Business Name): THOMAS JOHN CLEMENT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 MONROE ST
SYLVANIA OH
43560-2269
US

IV. Provider business mailing address

5705 SUN VALLEY BLVD
SYLVANIA OH
43560-3745
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-2273
  • Fax:
Mailing address:
  • Phone: 419-885-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004450
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: