Provider Demographics
NPI:1225624661
Name:CLEMENTS, ROBERT MALACHI (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MALACHI
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MORRIS CT
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-1727
Mailing Address - Country:US
Mailing Address - Phone:865-776-4215
Mailing Address - Fax:
Practice Address - Street 1:290 KEEL RD
Practice Address - Street 2:
Practice Address - City:GRANTSBORO
Practice Address - State:NC
Practice Address - Zip Code:28529-9424
Practice Address - Country:US
Practice Address - Phone:865-776-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7392225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant