Provider Demographics
NPI:1275963514
Name:CLACK, II, MARSHALL B II
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:B
Last Name:CLACK, II
Suffix:II
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 1:2323 FIELDSTONE DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1918
Mailing Address - Country:US
Mailing Address - Phone:770-710-3598
Mailing Address - Fax:
Practice Address - Street 1:1075 S MAIN ST
Practice Address - Street 2:ST 100
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2033
Practice Address - Country:US
Practice Address - Phone:706-752-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor