=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770079535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODDY CLEMENTS IDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 WAHOO AVE
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06349-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-694-1308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 WAHOO AVE
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06349-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1710I1002X
-----------------------------------------------------
Taxonomy Name | Independent Duty Corpsman
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------