Provider Demographics
NPI:1104211655
Name:LARK, SHENAN
Entity Type:Individual
Prefix:MR
First Name:SHENAN
Middle Name:
Last Name:LARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1522
Mailing Address - Street 2:
Mailing Address - City:ANGEL FIRE
Mailing Address - State:NM
Mailing Address - Zip Code:87710-1522
Mailing Address - Country:US
Mailing Address - Phone:505-603-9282
Mailing Address - Fax:
Practice Address - Street 1:28 ASPEN ST. # 205
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710
Practice Address - Country:US
Practice Address - Phone:505-603-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No172A00000XOther Service ProvidersDriver