MEDICARE: CLINT JASON DESOTO

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	171WH0202X	Home Modifications Contractor	89464	LA

General Provider Information

NPI Number	:	1326284563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINT JASON DESOTO

Provider Business Mailing Address
First Line	:	461 AIRBASE RD
Second Line	:
City	:	POLLOCK
State	:	LA
Zip	:	71467-3549
Country	:	US
Telephone Number	:	318-715-1792
Fax Number	:	318-765-7641

Provider Business Practice Location Address
First Line	:	461 AIRBASE RD
Second Line	:
City	:	POLLOCK
State	:	LA
Zip	:	71467-3549
Country	:	US
Telephone Number	:	318-715-1792
Fax Number	:	318-765-7641

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

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	12/17/2008

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Directions to “ CLINT JASON DESOTO ” Practice Location

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