1578692463 NPI number — SANDRA CLARK RT(R)

Table of content: SANDRA CLARK RT(R) (NPI 1578692463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578692463 NPI number — SANDRA CLARK RT(R)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
SANDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RT(R)
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
JASON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1578692463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 COUNTY ROAD 379
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATER VALLEY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38965-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-514-5215
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
139 COUNTY ROAD 379
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATER VALLEY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38965-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-514-5215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2007

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: 2471C3402X , with the licence number:  MRT2279 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09851011 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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