MEDICARE: ZACHARIAH SCOTT CLEMSEN LAT, PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	A00264	MD
2	225200000X	Physical Therapy Assistant	PTA011125	OH

General Provider Information

NPI Number	:	1023419710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARIAH SCOTT CLEMSEN LAT, PTA

Provider Business Mailing Address
First Line	:	18621 NEFF RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18621 NEFF RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3018
Country	:	US
Telephone Number	:	216-486-0268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2014
Last Update Date	:	02/26/2019

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