Individual
MISS ILEHA M CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
152 NEW ST STE 103M, MACON, GA 31201-7304
(478) 508-7124
Mailing address
152 NEW ST STE 103M, MACON, GA 31201-7304
(478) 259-1756
Taxonomy
Speciality
Code
Description
License number
State
251T00000X
PACE Provider Organization
Primary
—
—
372500000X
Chore Provider
—
—
Other
Enumeration date
04/23/2019
Last updated
05/03/2019
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