Healthcare Provider Details

I. General information

NPI: 1689269250
Provider Name (Legal Business Name): CLEMENTINE TWIN LAKES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11329 HENDERSON RD
FAIRFAX STATION VA
22039-2314
US

IV. Provider business mailing address

6100 SW 76TH ST
SOUTH MIAMI FL
33143-5002
US

V. Phone/Fax

Practice location:
  • Phone: 305-663-1876
  • Fax:
Mailing address:
  • Phone: 305-663-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE BAGLEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 305-663-1876