Provider Demographics
NPI:1033127188
Name:M L CLEMSON CORPORATION
Entity Type:Organization
Organization Name:M L CLEMSON CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CLEMSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY CNS
Authorized Official - Phone:757-622-6673
Mailing Address - Street 1:602 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2118
Mailing Address - Country:US
Mailing Address - Phone:757-622-6673
Mailing Address - Fax:757-622-1086
Practice Address - Street 1:602 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2118
Practice Address - Country:US
Practice Address - Phone:757-622-6673
Practice Address - Fax:757-622-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000529163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101867OtherANTHEM GROUP
VAC08982OtherMEDICARE
VA101868OtherANTHEM
VAP00071810OtherRAILROAD
VA1750563086OtherINDIVIDUAL NPI
VAP00071810OtherRAILROAD
VA00V835M82Medicare PIN