=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114094919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLOVER PHYSICAL THERAPY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3019 MONROE AVE SUITE 200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-354-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 LEEDS CIR
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-9428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-586-8867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RONALD CLARK WOOD III
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 585-354-1590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 021702
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------