Provider Demographics
NPI:1699517821
Name:CLARK, ANSENIO (MLT)
Entity type:Individual
Prefix:
First Name:ANSENIO
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 E TRINITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2897
Mailing Address - Country:US
Mailing Address - Phone:334-440-4538
Mailing Address - Fax:
Practice Address - Street 1:1565 E TRINITY BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2897
Practice Address - Country:US
Practice Address - Phone:334-440-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory