Provider Demographics
NPI:1760071013
Name:CLARK, RYAN J
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3874
Mailing Address - Country:US
Mailing Address - Phone:530-768-3952
Mailing Address - Fax:
Practice Address - Street 1:1300 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-3874
Practice Address - Country:US
Practice Address - Phone:530-768-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator