Healthcare Provider Details

I. General information

NPI: 1629577846
Provider Name (Legal Business Name): KIM MCCLENTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 CHAPMAN CIR
STONE MOUNTAIN GA
30088-2553
US

IV. Provider business mailing address

859 CHAPMAN CIR
STONE MOUNTAIN GA
30088-2553
US

V. Phone/Fax

Practice location:
  • Phone: 404-201-9075
  • Fax:
Mailing address:
  • Phone: 404-201-9075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: