Provider Demographics
NPI:1457471005
Name:CLEMMONS, ILLYA
Entity Type:Individual
Prefix:
First Name:ILLYA
Middle Name:
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10950 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-1024
Mailing Address - Country:US
Mailing Address - Phone:310-563-5639
Mailing Address - Fax:
Practice Address - Street 1:9512 ANZAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-2517
Practice Address - Country:US
Practice Address - Phone:323-564-1864
Practice Address - Fax:323-564-4892
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator