Provider Demographics
NPI:1083099279
Name:CLARK, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P13 AVON DR
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-5653
Mailing Address - Country:US
Mailing Address - Phone:910-977-0539
Mailing Address - Fax:
Practice Address - Street 1:P13 AVON DR
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR NJ
Practice Address - State:NJ
Practice Address - Zip Code:08520
Practice Address - Country:US
Practice Address - Phone:919-632-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00319500310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility