Provider Demographics
NPI:1275321150
Name:HARRIS, CLARENCE EDWARD JR
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:EDWARD
Last Name:HARRIS
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9241 NW 23RD PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-5195
Mailing Address - Country:US
Mailing Address - Phone:601-750-0410
Mailing Address - Fax:
Practice Address - Street 1:9241 NW 23RD PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-5195
Practice Address - Country:US
Practice Address - Phone:601-750-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907137311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home