Provider Demographics
NPI:1538556436
Name:CLARK, COLE
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:CLARK
Suffix:
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:PO BOX 264
Mailing Address - Street 2:103 SOUTH STREET
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-0264
Mailing Address - Country:US
Mailing Address - Phone:662-719-8217
Mailing Address - Fax:662-843-0002
Practice Address - Street 1:103 S COURT ST
Practice Address - Street 2:103 SOUTH STREET
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2651
Practice Address - Country:US
Practice Address - Phone:662-719-8217
Practice Address - Fax:662-843-0002
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care