Provider Demographics
NPI:1639492523
Name:CLARK, TYLER JOHN (RD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JOHN
Last Name:CLARK
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 BELMONT ST
Mailing Address - Street 2:FOOD AND NUTRITION SERVICES
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5596
Mailing Address - Country:US
Mailing Address - Phone:774-826-1439
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:FOOD AND NUTRITION SERVICES
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3061133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered