Healthcare Provider Details

I. General information

NPI: 1407780018
Provider Name (Legal Business Name): MARCUS CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7808 PURIFOY DR
WALLS MS
38680-0009
US

IV. Provider business mailing address

7808 PURIFOY DR
WALLS MS
38680-0009
US

V. Phone/Fax

Practice location:
  • Phone: 901-216-6650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: