Provider Demographics
NPI:1982022562
Name:CLARK, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 BROGDON RD
Mailing Address - Street 2:
Mailing Address - City:ALCOLU
Mailing Address - State:SC
Mailing Address - Zip Code:29001-8637
Mailing Address - Country:US
Mailing Address - Phone:202-403-7850
Mailing Address - Fax:
Practice Address - Street 1:2957 BROGDON RD
Practice Address - Street 2:
Practice Address - City:ALCOLU
Practice Address - State:SC
Practice Address - Zip Code:29001-8637
Practice Address - Country:US
Practice Address - Phone:202-403-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3205095343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)