Provider Demographics
NPI:1902652530
Name:CLARK, ERIC F SR
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:F
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N BRANDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8340
Mailing Address - Country:US
Mailing Address - Phone:601-942-2115
Mailing Address - Fax:
Practice Address - Street 1:450 N BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-8340
Practice Address - Country:US
Practice Address - Phone:601-942-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company