Provider Demographics
NPI:1003475880
Name:CLARK, RALPH
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:HINES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12003 S PULASKI RD APT 256
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-1221
Mailing Address - Country:US
Mailing Address - Phone:708-690-3845
Mailing Address - Fax:
Practice Address - Street 1:14847 VAIL AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1536
Practice Address - Country:US
Practice Address - Phone:773-724-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILC46272064039172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver