=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912074170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEMENS PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 W MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-1751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-842-6008
-----------------------------------------------------
Fax | 304-842-0060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 W MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-1751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-842-6008
-----------------------------------------------------
Fax | 304-842-0060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARNIE CLEMENS
-----------------------------------------------------
Credential | PT,DPT
-----------------------------------------------------
Telephone | 304-842-6008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 001091
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------