Provider Demographics
NPI:1114566965
Name:OBINWANNE, CLEMENT C
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:C
Last Name:OBINWANNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13049 CHEJU CIR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3901
Mailing Address - Country:US
Mailing Address - Phone:909-936-6542
Mailing Address - Fax:
Practice Address - Street 1:13049 CHEJU CIR
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-3901
Practice Address - Country:US
Practice Address - Phone:909-936-6542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist