Provider Demographics
NPI:1760462451
Name:CLARK AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:CLARK AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-445-5008
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0031
Mailing Address - Country:US
Mailing Address - Phone:770-445-5008
Mailing Address - Fax:770-505-7273
Practice Address - Street 1:117A COMMERCE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-5025
Practice Address - Country:US
Practice Address - Phone:770-445-2151
Practice Address - Fax:770-505-7273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA110-06341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00311165AMedicaid
GA00311165AMedicaid