MEDICARE: MICHELLE RENEE CLARK 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	PT14472	CA

General Provider Information

NPI Number	:	1699750778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE RENEE CLARK PT

Provider Business Mailing Address
First Line	:	40680 CALIFORNIA OAKS RD
Second Line	:	STE 2A
City	:	MURRIETA
State	:	CA
Zip	:	92562-5755
Country	:	US
Telephone Number	:	951-894-4800
Fax Number	:	951-894-4804

Provider Business Practice Location Address
First Line	:	25285 MADISON AVE
Second Line	:	SUITE 104
City	:	MURRIETA
State	:	CA
Zip	:	92562-8955
Country	:	US
Telephone Number	:	951-600-2990
Fax Number	:	951-600-7224

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

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	09/27/2020

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Directions to “ MICHELLE RENEE CLARK PT” Practice Location

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