Provider Demographics
NPI:1811777394
Name:CLARK, DEMETRIA GODFREY
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:GODFREY
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 FORT JACKSON BLVD APT 124
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1142
Mailing Address - Country:US
Mailing Address - Phone:803-238-9659
Mailing Address - Fax:893-887-5093
Practice Address - Street 1:4600 FORT JACKSON BLVD APT 124
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1142
Practice Address - Country:US
Practice Address - Phone:803-357-2268
Practice Address - Fax:803-887-5093
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBL002252-09-2023253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care