Provider Demographics
NPI:1518425792
Name:CLARK, QUINTON
Entity Type:Individual
Prefix:
First Name:QUINTON
Middle Name:
Last Name:CLARK
Suffix:
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 1:656 CAROLINA RD S
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-7770
Mailing Address - Country:US
Mailing Address - Phone:904-470-0196
Mailing Address - Fax:
Practice Address - Street 1:656 CAROLINA RD S
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-7770
Practice Address - Country:US
Practice Address - Phone:904-470-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty