Provider Demographics
NPI:1346496098
Name:MACKINNON, CLIFTON JAMES (OT/L)
Entity Type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:JAMES
Last Name:MACKINNON
Suffix:
Gender:M
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1777 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5130
Mailing Address - Country:US
Mailing Address - Phone:209-825-3696
Mailing Address - Fax:209-825-3697
Practice Address - Street 1:1070 STONUM LN
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-9490
Practice Address - Country:US
Practice Address - Phone:209-239-4258
Practice Address - Fax:209-239-4258
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1099225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist