Healthcare Provider Details

I. General information

NPI: 1801083134
Provider Name (Legal Business Name): CLEMENTS PROFESSIONAL ASSOCIATION PINE MOUNTAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 EAST BROAD ST
PINE MOUNTAIN GA
31822-0516
US

IV. Provider business mailing address

PO BOX 516
PINE MOUNTAIN GA
31822-0516
US

V. Phone/Fax

Practice location:
  • Phone: 706-663-2574
  • Fax: 706-663-5954
Mailing address:
  • Phone: 706-663-2574
  • Fax: 706-663-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA D CLEMENTS
Title or Position: VP SEC TRES AND MD
Credential: MD
Phone: 706-663-2574