Provider Demographics
NPI:1730764036
Name:THOM, ELI CLARK (DPT)
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:CLARK
Last Name:THOM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:RAIL ROAD FLAT
Mailing Address - State:CA
Mailing Address - Zip Code:95248-0518
Mailing Address - Country:US
Mailing Address - Phone:209-743-4058
Mailing Address - Fax:
Practice Address - Street 1:12150 INDUSTRY BLVD STE 42
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9375
Practice Address - Country:US
Practice Address - Phone:209-223-9410
Practice Address - Fax:209-223-9450
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist