Provider Demographics
NPI:1437252525
Name:CLARK, BRUCE M (CPO)
Entity Type:Individual
Prefix:PROF
First Name:BRUCE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24395 GREENFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-557-2323
Mailing Address - Fax:248-557-3639
Practice Address - Street 1:24395 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3118
Practice Address - Country:US
Practice Address - Phone:248-557-2323
Practice Address - Fax:248-557-3639
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI05096363Medicaid
MI05096363Medicaid