Provider Demographics
NPI:1033388061
Name:HARMON, CLYDE D JR
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:D
Last Name:HARMON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MS
Other - First Name:VALERIE
Other - Middle Name:
Other - Last Name:RORRER
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:CA
Mailing Address - Street 1:116 HANSON ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1615
Mailing Address - Country:US
Mailing Address - Phone:859-986-5636
Mailing Address - Fax:859-986-9124
Practice Address - Street 1:327 CHESTNUT ST
Practice Address - Street 2:SUITE#1
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1921
Practice Address - Country:US
Practice Address - Phone:859-986-5636
Practice Address - Fax:859-986-9124
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-24
Last Update Date:2008-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4157111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002053Medicaid
KYU50296Medicare UPIN
KY85002053Medicaid