Provider Demographics
NPI:1912525288
Name:CLOVER PODIATRY PLLC
Entity Type:Organization
Organization Name:CLOVER PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEK
Authorized Official - Middle Name:MANNING
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-450-6644
Mailing Address - Street 1:405 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2037
Mailing Address - Country:US
Mailing Address - Phone:360-450-6644
Mailing Address - Fax:360-524-7847
Practice Address - Street 1:405 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2037
Practice Address - Country:US
Practice Address - Phone:360-450-6644
Practice Address - Fax:360-524-7847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2169432Medicaid