Provider Demographics
NPI:1598462780
Name:BROWN, CLYDE ERIC
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:ERIC
Last Name:BROWN
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 1:3464 BLUEBRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-7457
Mailing Address - Country:US
Mailing Address - Phone:901-598-7663
Mailing Address - Fax:
Practice Address - Street 1:3464 BLUEBRIDGE CV
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-7457
Practice Address - Country:US
Practice Address - Phone:901-598-7663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN220007553343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)