Provider Demographics
NPI:1245603075
Name:SANDRA WEAVER CLARK
Entity Type:Organization
Organization Name:SANDRA WEAVER CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-946-9866
Mailing Address - Street 1:602 GEORGETOWN DR APT B
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-6132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 GEORGETOWN DR APT B
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-6132
Practice Address - Country:US
Practice Address - Phone:321-946-9866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009081000Medicaid