1174980007 NPI number — MRS. MYRA CLARK

Table of content: MRS. MYRA CLARK (NPI 1174980007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174980007 NPI number — MRS. MYRA CLARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MYRA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174980007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1377 MOHICAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35214-3811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-705-6104
Provider Business Mailing Address Fax Number:
205-637-7848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1377 MOHICAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35214-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-705-6104
Provider Business Practice Location Address Fax Number:
205-637-7848
Provider Enumeration Date:
01/22/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  16003458 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)