Provider Demographics
NPI:1518557073
Name:MOUNTAINSIDE PEDIATRIC AND ADOLESCENT CLINIC, PLLC
Entity Type:Organization
Organization Name:MOUNTAINSIDE PEDIATRIC AND ADOLESCENT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-982-2721
Mailing Address - Street 1:995 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:NC
Mailing Address - Zip Code:28901-7087
Mailing Address - Country:US
Mailing Address - Phone:828-321-3210
Mailing Address - Fax:828-321-3211
Practice Address - Street 1:995 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:NC
Practice Address - Zip Code:28901-7087
Practice Address - Country:US
Practice Address - Phone:828-321-3210
Practice Address - Fax:828-321-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty