1346616208 NPI number — MR. KEITH ANDREW CLARKE CPT, CMT

Table of content: MR. KEITH ANDREW CLARKE CPT, CMT (NPI 1346616208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346616208 NPI number — MR. KEITH ANDREW CLARKE CPT, CMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
KEITH
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CPT, CMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346616208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 W G ST # 819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92101-6096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-906-7055
Provider Business Mailing Address Fax Number:
619-639-8269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3975 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-3101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-906-7055
Provider Business Practice Location Address Fax Number:
619-639-8269
Provider Enumeration Date:
08/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  67117 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 67117 . This is a "CALIFORNIA MASSAGE THERAPY COUNCIL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1346616208 . This is a "NPPES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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