Provider Demographics
NPI:1487231494
Name:MCCLENDON, CORNELIUS III (CPI, CBRF)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:MCCLENDON
Suffix:III
Gender:M
Credentials:CPI, CBRF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5277 N 29TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4853
Mailing Address - Country:US
Mailing Address - Phone:262-757-5210
Mailing Address - Fax:
Practice Address - Street 1:5277 N 29TH ST APT 1
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4853
Practice Address - Country:US
Practice Address - Phone:262-757-5210
Practice Address - Fax:414-800-1707
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00166203104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness