Provider Demographics
NPI:1790078616
Name:CLARKE, MURRAY (LAC)
Entity Type:Individual
Prefix:
First Name:MURRAY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 WILSHIRE BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1872
Practice Address - Country:US
Practice Address - Phone:310-395-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3261133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist