Provider Demographics
NPI:1629842034
Name:CLARK, DEVORE SR (QBHS)
Entity Type:Individual
Prefix:
First Name:DEVORE
Middle Name:
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:QBHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4429 WESTWAY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-2152
Mailing Address - Country:US
Mailing Address - Phone:567-377-7279
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1230
Practice Address - Country:US
Practice Address - Phone:567-321-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator