Provider Demographics
NPI:1124458088
Name:MCCLINTOCK, KEVIN (ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MCCLINTOCK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14448 WAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1742
Mailing Address - Country:US
Mailing Address - Phone:510-483-2835
Mailing Address - Fax:
Practice Address - Street 1:12500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-3107
Practice Address - Country:US
Practice Address - Phone:510-436-2659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer