1992894992 NPI number — FRED R CLARK LSW

Table of content: FRED R CLARK LSW (NPI 1992894992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992894992 NPI number — FRED R CLARK LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
FRED
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992894992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 SUMMERBROOK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURRICANE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-525-7851
Provider Business Mailing Address Fax Number:
304-525-1073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 GROSSCUP AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNBAR
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25064-3128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-525-7851
Provider Business Practice Location Address Fax Number:
304-525-1073
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  AP00941076 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 1704 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP00941076 . This is a "LSW" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1704 . This is a "LPC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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