Healthcare Provider Details

I. General information

NPI: 1154556041
Provider Name (Legal Business Name): EDUARDO F CLEMENTE IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3278 MITCHELL BLVD
MOODY A F B GA
31699-1500
US

IV. Provider business mailing address

3807 SEDGEFIELD DR
VALDOSTA GA
31605-6440
US

V. Phone/Fax

Practice location:
  • Phone: 229-257-5188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: