Provider Demographics
NPI:1093360802
Name:CLARK, TIMIERA (OWNER)
Entity Type:Individual
Prefix:
First Name:TIMIERA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:TIMIERA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5601 BRIDGE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2355
Mailing Address - Country:US
Mailing Address - Phone:817-902-8085
Mailing Address - Fax:
Practice Address - Street 1:5601 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2355
Practice Address - Country:US
Practice Address - Phone:817-902-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0194283747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider