Provider Demographics
NPI:1265618953
Name:ADRA ETHO
Entity type:Organization
Organization Name:ADRA ETHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-637-6415
Mailing Address - Street 1:10567 SAWMILL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6667
Mailing Address - Country:US
Mailing Address - Phone:614-210-1885
Mailing Address - Fax:
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-637-6415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty