Provider Demographics
NPI:1538703582
Name:AVERY, HAROLD DARRNELL SR
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:DARRNELL
Last Name:AVERY
Suffix:SR
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 1:3757 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-3529
Mailing Address - Country:US
Mailing Address - Phone:901-618-7153
Mailing Address - Fax:
Practice Address - Street 1:3757 SKYLARK DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-3529
Practice Address - Country:US
Practice Address - Phone:901-618-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN071794750343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN071794750OtherDRIVER LICENSE NUMBER