Provider Demographics
NPI:1447218524
Name:NANCY COPPIC CLARK OD
Entity Type:Organization
Organization Name:NANCY COPPIC CLARK OD
Other - Org Name:NANCY COPPIC CLARK OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:COPPIC
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:434-793-6912
Mailing Address - Street 1:123 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2863
Mailing Address - Country:US
Mailing Address - Phone:434-793-6912
Mailing Address - Fax:434-799-8641
Practice Address - Street 1:123 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2863
Practice Address - Country:US
Practice Address - Phone:434-793-6912
Practice Address - Fax:434-799-8641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08996Medicare PIN
VA5130410001Medicare NSC