Provider Demographics
NPI:1578992962
Name:CLEGAIL PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:CLEGAIL PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SOWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-825-7223
Mailing Address - Street 1:5635 HORNADAY RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 ASKEW ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-2201
Practice Address - Country:US
Practice Address - Phone:336-825-7223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility