Provider Demographics
NPI:1104207943
Name:MCCLAIN, MICHAEL A (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:PTA
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 2860
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-2860
Mailing Address - Country:US
Mailing Address - Phone:575-439-1397
Mailing Address - Fax:575-437-2622
Practice Address - Street 1:601 W MAHONE DR
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-2046
Practice Address - Country:US
Practice Address - Phone:575-746-2566
Practice Address - Fax:575-746-6260
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant