Provider Demographics
NPI:1922557735
Name:FAIRCLOTH, CLAYTON (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 IVEY DR SW
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3760
Mailing Address - Country:US
Mailing Address - Phone:912-687-1080
Mailing Address - Fax:
Practice Address - Street 1:208 IVEY DR SW
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3760
Practice Address - Country:US
Practice Address - Phone:912-687-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0029242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer