1639373913 NPI number — LAWRENCE E CLARK MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639373913 NPI number — LAWRENCE E CLARK MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE E CLARK MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639373913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 14TH ST
Provider Second Line Business Mailing Address:
STE 302
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92501-4083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-682-3583
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 14TH ST
Provider Second Line Business Practice Location Address:
STE 302
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-682-3583
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
951-682-3583

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G435560 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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