Basic Information
| Provider Information | |||||||||
| NPI: | 1609536713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMMONS | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 1ST ST APT 203 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483072672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106259474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5821 W MAPLE RD STE 195 | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483222275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488310293 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2021 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.