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General NPI Number Information
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NPI Number | 1912185927
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Entity Type | Organization
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Legal Business Name | JASON H CLARK & SANDRA J CLARK
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Dates
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Enumeration Date | 02/01/2008
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Last Update Date | 12/03/2008
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Provider Practice Location Address
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Address Line | 139 COUNTY ROAD 379
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City | WATER VALLEY
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State | MS
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Zip | 38965-3607
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Country | US
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Telephone | 662-514-5215
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Fax | 662-234-0172
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Provider Business Mailing Address
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Address Line | PO BOX 994
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City | OXFORD
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State | MS
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Zip | 38655-0994
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Country | US
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Telephone | 662-514-5215
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Fax | 662-234-0172
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Authorized Official
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Title or Position | OWNER
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Name | JASON CLARK
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Credential |
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Telephone | 662-514-5215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335V00000X
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Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
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License Number | MRT2279
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License Number State | MS
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