Provider Demographics
NPI:1356825020
Name:CLARK, R.L. JR
Entity Type:Individual
Prefix:DR
First Name:R.L.
Middle Name:
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 1:2637 EDENBORN AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-7042
Mailing Address - Country:US
Mailing Address - Phone:504-455-2446
Mailing Address - Fax:504-455-7626
Practice Address - Street 1:2637 EDENBORN AVE STE 302
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-7042
Practice Address - Country:US
Practice Address - Phone:504-455-2446
Practice Address - Fax:504-455-7626
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator