Provider Demographics
NPI:1396561197
Name:CLARK, RAYMOND (BA)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-3312
Mailing Address - Country:US
Mailing Address - Phone:925-705-0748
Mailing Address - Fax:
Practice Address - Street 1:300 ILENE ST
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-2631
Practice Address - Country:US
Practice Address - Phone:925-313-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist