Provider Demographics
NPI:1740452218
Name:CLARK, COLIE BOB JR (BS, CCP, LP)
Entity type:Individual
Prefix:MR
First Name:COLIE
Middle Name:BOB
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:BS, CCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 CARRIAGE TRL
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-8508
Mailing Address - Country:US
Mailing Address - Phone:919-880-3688
Mailing Address - Fax:
Practice Address - Street 1:3101 CARRIAGE TRL
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-8508
Practice Address - Country:US
Practice Address - Phone:919-880-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist