=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235268186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLYDE L. IMHOFF, JR. D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 W 8TH ST
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-4325
-----------------------------------------------------
Fax | 928-782-4326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 W 8TH ST
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-4325
-----------------------------------------------------
Fax | 928-782-4326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number | 1062
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------