Provider Demographics
NPI:1366689903
Name:CLARK AUDIOLOGY LLC
Entity Type:Organization
Organization Name:CLARK AUDIOLOGY LLC
Other - Org Name:AUDIOLOGY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:513-422-6516
Mailing Address - Street 1:1060 A SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3400
Mailing Address - Country:US
Mailing Address - Phone:513-422-6516
Mailing Address - Fax:513-422-5199
Practice Address - Street 1:1060 A SUMMIT DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3400
Practice Address - Country:US
Practice Address - Phone:513-422-6516
Practice Address - Fax:513-422-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCL9334841Medicare PIN