Provider Demographics
NPI:1972234227
Name:MELONSON, CLARK WAYNE
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:WAYNE
Last Name:MELONSON
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 1:701 COUNTY ROAD 154
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-9305
Mailing Address - Country:US
Mailing Address - Phone:281-636-6979
Mailing Address - Fax:
Practice Address - Street 1:701 COUNTY ROAD 154
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-9305
Practice Address - Country:US
Practice Address - Phone:281-636-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)