Provider Demographics
NPI:1629258140
Name:CLARK ORTHOTIC SERVICES, INC.
Entity Type:Organization
Organization Name:CLARK ORTHOTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:CO, LO
Authorized Official - Phone:614-863-6900
Mailing Address - Street 1:6315 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1506
Mailing Address - Country:US
Mailing Address - Phone:614-863-6900
Mailing Address - Fax:614-863-8787
Practice Address - Street 1:6315 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1506
Practice Address - Country:US
Practice Address - Phone:614-863-6900
Practice Address - Fax:614-863-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0345600001Medicare NSC