Provider Demographics
NPI:1528616547
Name:PHILLIPS, CLIVE
Entity type:Individual
Prefix:MR
First Name:CLIVE
Middle Name:
Last Name:PHILLIPS
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 1:6755 NW MONOCO CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-5339
Mailing Address - Country:US
Mailing Address - Phone:772-237-2496
Mailing Address - Fax:772-237-2496
Practice Address - Street 1:6755 NW MONOCO CT
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-5339
Practice Address - Country:US
Practice Address - Phone:772-237-2496
Practice Address - Fax:772-237-2496
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906987311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home