Basic Information
| Provider Information | |||||||||
| NPI: | 1215912498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLELAND | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1983 COMMERCE CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863014454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287711700 | ||||||||
| FaxNumber: | 9287719900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1983 COMMERCE CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863014454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287711700 | ||||||||
| FaxNumber: | 9287719900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 8290 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5626 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 679951 | 05 | AZ | MEDICAID |