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Organization
CLEMENTINE TWIN LAKES, LLC
Active
Organization
CLEMENTINE TWIN LAKES, LLC
Active
Other names
Clementine Fairfax
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MIKE BAGLEY (CHIEF FINANCIAL OFFICER)
(305) 663-1876
Entity
Organization
Contact information
Practice address
11329 HENDERSON RD, FAIRFAX STATION, VA 22039-2314
(305) 663-1876
Mailing address
6100 SW 76TH ST, SOUTH MIAMI, FL 33143-5002
(305) 663-1876
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
NULL
320800000X
Mental Illness Community Based Residential Treatment Facility
—
NULL
323P00000X
Psychiatric Residential Treatment Facility
Primary
—
NULL
Other
Enumeration date
03/05/2021
Last updated
10/16/2025
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