Provider Demographics
NPI:1043705924
Name:CLARK, KETURAH S
Entity Type:Individual
Prefix:
First Name:KETURAH
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15622
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-0622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:936 EXCHANGE ST STE E-103
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-2801
Practice Address - Country:US
Practice Address - Phone:585-351-8391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-24
Last Update Date:2018-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist