Provider Demographics
NPI:1518233063
Name:MCCLURE, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MCCLURE
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 1:5346 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4018
Mailing Address - Country:US
Mailing Address - Phone:352-427-9076
Mailing Address - Fax:904-300-3558
Practice Address - Street 1:5346 FREMONT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-4018
Practice Address - Country:US
Practice Address - Phone:352-427-9076
Practice Address - Fax:904-300-3558
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004372900OtherMEDICAID WAIVER PROVIDER I.D.