Provider Demographics
NPI:1952056673
Name:CLARK, ERIC C
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
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 1:5122 GLENCROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-3361
Mailing Address - Country:US
Mailing Address - Phone:513-827-9044
Mailing Address - Fax:
Practice Address - Street 1:5122 GLENCROSSING WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3361
Practice Address - Country:US
Practice Address - Phone:513-827-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator