Provider Demographics
NPI:1295579555
Name:CLEMMONS DERMATOLOGY
Entity type:Organization
Organization Name:CLEMMONS DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-416-4093
Mailing Address - Street 1:2515 LEWISVILLE CLEMMONS RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8712
Mailing Address - Country:US
Mailing Address - Phone:336-416-4093
Mailing Address - Fax:
Practice Address - Street 1:2515 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8712
Practice Address - Country:US
Practice Address - Phone:336-416-4093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty