Provider Demographics
NPI:1902632904
Name:CLEMENTINE HEALTH AND WELLNESS
Entity type:Organization
Organization Name:CLEMENTINE HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-204-3429
Mailing Address - Street 1:225 E CHEYENNE MOUNTAIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E CHEYENNE MOUNTAIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3700
Practice Address - Country:US
Practice Address - Phone:719-204-3429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty