Provider Demographics
NPI:1518135623
Name:MCCLELLAN, SILAS MOJAVE (LMT)
Entity Type:Individual
Prefix:MR
First Name:SILAS
Middle Name:MOJAVE
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:SILAS
Other - Middle Name:MOJAVE
Other - Last Name:MCCLELLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:5170 SW 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-5767
Mailing Address - Country:US
Mailing Address - Phone:754-422-7809
Mailing Address - Fax:
Practice Address - Street 1:150 S ANDREWS AVE STE 410
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3219
Practice Address - Country:US
Practice Address - Phone:954-941-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 38166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist