Provider Demographics
NPI:1104711183
Name:CLARK, ERIC B JR
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:B
Last Name:CLARK
Suffix:JR
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 1:4060 VINTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-3863
Mailing Address - Country:US
Mailing Address - Phone:402-991-9880
Mailing Address - Fax:402-625-0081
Practice Address - Street 1:670 S 69TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-1004
Practice Address - Country:US
Practice Address - Phone:402-612-8805
Practice Address - Fax:402-612-8805
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide