# CLEMENTINE TWIN LAKES, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Clementine Fairfax
- **Organization subpart:** No

## Provider details

- **NPI number:** 1689269250
- **Authorized official:** MR. MIKE BAGLEY (CHIEF FINANCIAL OFFICER)
- **Authorized official phone:** (305) 663-1876

## Contact information

- **Practice address:** 11329 HENDERSON RD, FAIRFAX STATION, VA 22039-2314
- **Practice address phone:** (305) 663-1876
- **Mailing address:** 6100 SW 76TH ST, SOUTH MIAMI, FL 33143-5002
- **Mailing address phone:** (305) 663-1876

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM0855X | Adolescent and Children Mental Health Clinic/Center | — | NULL | — |
| 320800000X | Mental Illness Community Based Residential Treatment Facility | — | NULL | — |
| 323P00000X | Psychiatric Residential Treatment Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 03/05/2021
- **Last updated:** 10/16/2025