Provider Demographics
NPI:1841649779
Name:CHRISTINE C CLARK LTD
Entity type:Organization
Organization Name:CHRISTINE C CLARK LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:CARON
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-642-4405
Mailing Address - Street 1:2441 TECH CENTER CT
Mailing Address - Street 2:#103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0804
Mailing Address - Country:US
Mailing Address - Phone:702-642-4405
Mailing Address - Fax:702-642-6775
Practice Address - Street 1:2441 TECH CENTER CT
Practice Address - Street 2:#103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0804
Practice Address - Country:US
Practice Address - Phone:702-642-4405
Practice Address - Fax:702-642-6775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV8702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty