Provider Demographics
NPI:1679256614
Name:BROWN, CLYDE JR
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:BROWN
Suffix:JR
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 1:306 CARR MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1821
Mailing Address - Country:US
Mailing Address - Phone:601-291-6576
Mailing Address - Fax:
Practice Address - Street 1:306 CARR MEADOW DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1821
Practice Address - Country:US
Practice Address - Phone:601-291-6576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS802049034343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)