Healthcare Provider Details

I. General information

NPI: 1154690360
Provider Name (Legal Business Name): REBEKAH JEANNE MCCLEAREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

1609 8TH ST
PORT HURON MI
48060-5841
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number246734385734
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: