Provider Demographics
NPI:1952869257
Name:LORI J CLARK, O.D. INC, AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:LORI J CLARK, O.D. INC, AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-546-4618
Mailing Address - Street 1:1145 MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5333
Mailing Address - Country:US
Mailing Address - Phone:310-546-4618
Mailing Address - Fax:310-546-9268
Practice Address - Street 1:1145 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5333
Practice Address - Country:US
Practice Address - Phone:310-546-4618
Practice Address - Fax:310-546-9268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089501Medicaid