MEDICARE: ELI CLARK THOM DPT

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	299903	CA

General Provider Information

NPI Number	:	1730764036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELI CLARK THOM DPT

Provider Business Mailing Address
First Line	:	PO BOX 518
Second Line	:
City	:	RAIL ROAD FLAT
State	:	CA
Zip	:	95248-0518
Country	:	US
Telephone Number	:	209-743-4058
Fax Number	:

Provider Business Practice Location Address
First Line	:	12150 INDUSTRY BLVD STE 42
Second Line	:
City	:	JACKSON
State	:	CA
Zip	:	95642-9375
Country	:	US
Telephone Number	:	209-223-9410
Fax Number	:	209-223-9450

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

Provider Enumeration Date	:	03/17/2021
Last Update Date	:	03/17/2021

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Directions to “ ELI CLARK THOM DPT” Practice Location

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