Provider Demographics
NPI:1184764870
Name:CLARY-TRIMM, BETTY (PT 14194)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:
Last Name:CLARY-TRIMM
Suffix:
Gender:F
Credentials:PT 14194
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 3204
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-3204
Mailing Address - Country:US
Mailing Address - Phone:760-344-9000
Mailing Address - Fax:760-344-9191
Practice Address - Street 1:529 E ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-1930
Practice Address - Country:US
Practice Address - Phone:760-344-9000
Practice Address - Fax:760-344-9191
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT14194AMedicare ID - Type Unspecified