Provider Demographics
NPI:1922244425
Name:THE ANAPLASTOLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:THE ANAPLASTOLOGY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ANAPLASTOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:MCCLENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:CCA, CFM
Authorized Official - Phone:919-383-1205
Mailing Address - Street 1:2613 CARVER ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2720
Mailing Address - Country:US
Mailing Address - Phone:919-383-1205
Mailing Address - Fax:919-383-2838
Practice Address - Street 1:2613 CARVER ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2720
Practice Address - Country:US
Practice Address - Phone:919-383-1205
Practice Address - Fax:919-383-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6162480001Medicare NSC