Provider Demographics
NPI:1023362373
Name:SMITH, CLEMENT GUSTAVOUS (CAREGIVER)
Entity Type:Individual
Prefix:MR
First Name:CLEMENT
Middle Name:GUSTAVOUS
Last Name:SMITH
Suffix:
Gender:M
Credentials:CAREGIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 JODY STREET
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948
Mailing Address - Country:US
Mailing Address - Phone:941-764-7461
Mailing Address - Fax:941-764-7461
Practice Address - Street 1:3081 JODY STREET
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948
Practice Address - Country:US
Practice Address - Phone:941-764-7461
Practice Address - Fax:941-764-7461
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000957800Medicaid