Provider Demographics
NPI:1043875263
Name:CLARK-GREEN, KIM
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:CLARK-GREEN
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 1:4111 METRO DR STE B
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-6001
Mailing Address - Country:US
Mailing Address - Phone:318-636-0390
Mailing Address - Fax:318-635-3298
Practice Address - Street 1:4111 METRO DR STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-6001
Practice Address - Country:US
Practice Address - Phone:318-636-0390
Practice Address - Fax:318-635-3298
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator