Provider Demographics
NPI:1679580773
Name:SUSAN K CLARK
Entity Type:Organization
Organization Name:SUSAN K CLARK
Other - Org Name:LACTATION MANGEMENT SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, IBCLC
Authorized Official - Phone:989-832-8322
Mailing Address - Street 1:310 SEMINOLE COURT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3572
Mailing Address - Country:US
Mailing Address - Phone:989-832-8322
Mailing Address - Fax:
Practice Address - Street 1:310 SEMINOLE COURT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-3572
Practice Address - Country:US
Practice Address - Phone:989-832-8322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4668053Medicaid