Provider Demographics
NPI:1477377273
Name:CLARK, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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 1:810 LINDEN MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-5082
Mailing Address - Country:US
Mailing Address - Phone:502-523-7767
Mailing Address - Fax:
Practice Address - Street 1:810 LINDEN MEADOWS CT
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-5082
Practice Address - Country:US
Practice Address - Phone:502-523-7767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-09
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2401834613747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant