Basic Information
Provider Information | |||||||||
NPI: | 1245563295 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLURE-SMITH | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | LEANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24630 WASHINGTON AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925626177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516969353 | ||||||||
FaxNumber: | 9519737216 | ||||||||
Practice Location | |||||||||
Address1: | 27450 YNEZ RD | ||||||||
Address2: | SUITE 120 | ||||||||
City: | TEMECULA | ||||||||
State: | CA | ||||||||
PostalCode: | 925914671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516955144 | ||||||||
FaxNumber: | 9516959345 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2009 | ||||||||
LastUpdateDate: | 09/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT36002 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.