Provider Demographics
NPI:1427580372
Name:CLARK, MARIE
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2353
Mailing Address - Country:US
Mailing Address - Phone:541-914-3659
Mailing Address - Fax:
Practice Address - Street 1:1842 GROVE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2353
Practice Address - Country:US
Practice Address - Phone:541-914-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR190854156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician