Basic Information
| Provider Information | |||||||||
| NPI: | 1508382797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEVERLY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | CHASE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3859 S ASHLEAF LN | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454403472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374437311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 MIAMI VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374382400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 390200000X | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2255A2300X | AT006151 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.