Provider Demographics
NPI:1821737438
Name:CLEMENTS, COBURN SHELL
Entity Type:Individual
Prefix:
First Name:COBURN
Middle Name:SHELL
Last Name:CLEMENTS
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 1:1600 WESTBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-3337
Mailing Address - Country:US
Mailing Address - Phone:804-551-2310
Mailing Address - Fax:
Practice Address - Street 1:1600 WESTBROOK AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-3337
Practice Address - Country:US
Practice Address - Phone:804-551-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist