Provider Demographics
NPI:1477960466
Name:MCCLURE, DEREK (BOCPO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 BROADWAY ST
Mailing Address - Street 2:STE. # B3
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1229
Mailing Address - Country:US
Mailing Address - Phone:707-643-2177
Mailing Address - Fax:707-643-6339
Practice Address - Street 1:3433 BROADWAY ST
Practice Address - Street 2:STE. # B3
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1229
Practice Address - Country:US
Practice Address - Phone:707-643-2177
Practice Address - Fax:707-643-6339
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZC46700224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist