Provider Demographics
NPI:1427787647
Name:CLARK, REBECCA ELLEN
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:ELLEN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2405 RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:OH
Mailing Address - Zip Code:44822-9635
Mailing Address - Country:US
Mailing Address - Phone:419-564-6858
Mailing Address - Fax:
Practice Address - Street 1:2405 RAMSEY RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:OH
Practice Address - Zip Code:44822-9635
Practice Address - Country:US
Practice Address - Phone:419-564-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)