Healthcare Provider Details

I. General information

NPI: 1659438455
Provider Name (Legal Business Name): DALE S CLEMENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 FRANKLIN PARK DR
EAST SYRACUSE NY
13057-1614
US

IV. Provider business mailing address

824 FRANKLIN PARK DR
EAST SYRACUSE NY
13057-1614
US

V. Phone/Fax

Practice location:
  • Phone: 315-446-1288
  • Fax: 315-463-2210
Mailing address:
  • Phone: 315-446-1288
  • Fax: 315-463-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License NumberC006828
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberC006828
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: