Provider Demographics
NPI:1427355486
Name:CLEMONS TRANSPORT
Entity type:Organization
Organization Name:CLEMONS TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-873-6431
Mailing Address - Street 1:1845 CLEARLAKE TRCE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-4005
Mailing Address - Country:US
Mailing Address - Phone:770-873-6431
Mailing Address - Fax:770-593-3743
Practice Address - Street 1:1845 CLEARLAKE TRCE
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-4005
Practice Address - Country:US
Practice Address - Phone:770-873-6431
Practice Address - Fax:770-593-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00225751343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00225751OtherBUSINESS AND OCCUPATIONAL TAX CERTIFICATE