Healthcare Provider Details

I. General information

NPI: 1346990769
Provider Name (Legal Business Name): MORGAN CLANCY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 03/28/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

3245 KITCHEN DR
CARSON CITY NV
89701-6166
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone: 775-721-0047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number208D00000X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: