Provider Demographics
NPI:1790549582
Name:CLEMENS, MARY (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 WITTINGTON PL APT 266
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-1976
Mailing Address - Country:US
Mailing Address - Phone:661-839-7897
Mailing Address - Fax:
Practice Address - Street 1:4000 N MACARTHUR BLVD STE 111
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6400
Practice Address - Country:US
Practice Address - Phone:469-565-2354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor