Provider Demographics
NPI:1013141696
Name:DR. KIM M CLARK & ASSOCIATES LLC
Entity type:Organization
Organization Name:DR. KIM M CLARK & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-292-4033
Mailing Address - Street 1:2318 NW EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7618
Mailing Address - Country:US
Mailing Address - Phone:503-292-4033
Mailing Address - Fax:503-292-2474
Practice Address - Street 1:12000 SE 82ND AVENUE
Practice Address - Street 2:#2012
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7721
Practice Address - Country:US
Practice Address - Phone:503-652-6001
Practice Address - Fax:503-652-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2911ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000009413Medicare UPIN