MEDICARE: MR. CLARENCE WILBORN TAPLEY III PT

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	225100000X	Physical Therapist	PT1029	MS

General Provider Information

NPI Number	:	1376978361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARENCE WILBORN TAPLEY III PT

Provider Business Mailing Address
First Line	:	1149 N JACKSON ST
Second Line	:
City	:	HOUSTON
State	:	MS
Zip	:	38851-8273
Country	:	US
Telephone Number	:	662-542-0491
Fax Number	:

Provider Business Practice Location Address
First Line	:	1149 N JACKSON ST
Second Line	:
City	:	HOUSTON
State	:	MS
Zip	:	38851-8273
Country	:	US
Telephone Number	:	662-542-0491
Fax Number	:

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

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	09/09/2013

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