Provider Demographics
NPI:1568949469
Name:CLARK, ROBIN ARDELLE
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:ARDELLE
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:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-1927
Mailing Address - Country:US
Mailing Address - Phone:909-866-5070
Mailing Address - Fax:
Practice Address - Street 1:32270 OLD WOMAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LUCERNE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92356
Practice Address - Country:US
Practice Address - Phone:760-248-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker