MEDICARE: DR. CLIFTON JAMES CLENDENAN DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301002785	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	95OD450100	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1790890036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFTON JAMES CLENDENAN DC

Provider Business Mailing Address
First Line	:	PO BOX 127
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-0127
Country	:	US
Telephone Number	:	810-724-0596
Fax Number	:	810-724-2247

Provider Business Practice Location Address
First Line	:	279 W CAPAC RD
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-1071
Country	:	US
Telephone Number	:	810-724-0596
Fax Number	:	810-724-2247

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/09/2007

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