Healthcare Provider Details

I. General information

NPI: 1053216168
Provider Name (Legal Business Name): RYAN MICHAEL CLEMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 N US HIGHWAY 129
BELL FL
32619-3319
US

IV. Provider business mailing address

3250 N US HIGHWAY 129
BELL FL
32619-3319
US

V. Phone/Fax

Practice location:
  • Phone: 386-935-5400
  • Fax:
Mailing address:
  • Phone: 386-935-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberCCHW.0100574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: