Provider Demographics
NPI:1588156988
Name:CLEMENT, MICHE
Entity type:Individual
Prefix:
First Name:MICHE
Middle Name:
Last Name:CLEMENT
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:PO BOX 11502
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-1502
Mailing Address - Country:US
Mailing Address - Phone:954-471-1771
Mailing Address - Fax:
Practice Address - Street 1:209 S HALIFAX AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-6814
Practice Address - Country:US
Practice Address - Phone:954-471-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81-1179377Medicaid