Provider Demographics
NPI:1598231011
Name:CLARK, SANTAGO
Entity Type:Individual
Prefix:MR
First Name:SANTAGO
Middle Name:
Last Name:CLARK
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 1:4607 TRIAL DR.
Mailing Address - Street 2:
Mailing Address - City:ADDIS
Mailing Address - State:LA
Mailing Address - Zip Code:70710
Mailing Address - Country:US
Mailing Address - Phone:225-907-6659
Mailing Address - Fax:
Practice Address - Street 1:4607 TRIAL DR.
Practice Address - Street 2:
Practice Address - City:ADDIS
Practice Address - State:LA
Practice Address - Zip Code:70710
Practice Address - Country:US
Practice Address - Phone:225-907-6659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver