Provider Demographics
NPI:1184987935
Name:COPELAND, CLYDE
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:COPELAND
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 1:5465 SCENIC HTS
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31816-6839
Mailing Address - Country:US
Mailing Address - Phone:706-846-5410
Mailing Address - Fax:
Practice Address - Street 1:5465 SCENIC HTS
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:GA
Practice Address - Zip Code:31816
Practice Address - Country:US
Practice Address - Phone:706-846-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver