Provider Demographics
NPI:1174980007
Name:CLARK, MYRA
Entity type:Individual
Prefix:MRS
First Name:MYRA
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 1:1377 MOHICAN DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35214-3811
Mailing Address - Country:US
Mailing Address - Phone:205-705-6104
Mailing Address - Fax:205-637-7848
Practice Address - Street 1:1377 MOHICAN DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35214-3811
Practice Address - Country:US
Practice Address - Phone:205-705-6104
Practice Address - Fax:205-637-7848
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16003458343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)