Provider Demographics
NPI:1851398119
Name:BORMAN, CLINTON (DPT, MTC)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:BORMAN
Suffix:
Gender:M
Credentials:DPT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 W DEER VALLEY RD STE 100
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2101
Mailing Address - Country:US
Mailing Address - Phone:623-376-9100
Mailing Address - Fax:
Practice Address - Street 1:7707 W DEER VALLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2101
Practice Address - Country:US
Practice Address - Phone:623-376-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ803660Medicaid
AZ75294Medicare ID - Type Unspecified