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General NPI Number Information
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NPI Number | 1518141407
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Entity Type | Organization
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Legal Business Name | CLEMMONS URGENT AND PRIMARY CARE, PA
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Dates
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Enumeration Date | 12/27/2007
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Last Update Date | 07/11/2013
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Provider Practice Location Address
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Address Line | 2245 LEWISVILLE CLEMMONS RD STE C
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City | CLEMMONS
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State | NC
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Zip | 27012-7461
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Country | US
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Telephone | 336-712-8225
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Fax | 336-712-8227
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Provider Business Mailing Address
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Address Line | 2245 LEWISVILLE CLEMMONS RD STE C
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City | CLEMMONS
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State | NC
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Zip | 27012-7461
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Country | US
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Telephone | 336-712-8225
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Fax | 336-712-8227
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Authorized Official
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Title or Position | OWNER/ ONLY PROVIDER
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Name | DR. ARIE MANTIN
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Credential | M.D.
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Telephone | 336-712-8225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 200000535
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License Number State | NC
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