Provider Demographics
NPI:1487369229
Name:MAGNO, CLINTON MELLIZA
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:MELLIZA
Last Name:MAGNO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 PARK PL
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-1336
Mailing Address - Country:US
Mailing Address - Phone:608-577-9044
Mailing Address - Fax:
Practice Address - Street 1:2121 PIONEER DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3025
Practice Address - Country:US
Practice Address - Phone:608-365-9526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042424-01225100000X
MA24302225100000X
WI14502-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist