Provider Demographics
NPI:1679189989
Name:DECLARKE, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:DECLARKE
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 1:915 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1723
Mailing Address - Country:US
Mailing Address - Phone:269-945-3866
Mailing Address - Fax:269-945-9388
Practice Address - Street 1:915 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1723
Practice Address - Country:US
Practice Address - Phone:269-945-3866
Practice Address - Fax:269-945-9388
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005439152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist