Healthcare Provider Details

I. General information

NPI: 1144732769
Provider Name (Legal Business Name): JCAOB MATTHEW CLEMENTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2017
Last Update Date: 11/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NW 56TH TER
GAINESVILLE FL
32605-4481
US

IV. Provider business mailing address

175 MIDDLE ST UNIT 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 352-835-5520
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax: 866-610-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: