1760500623 NPI number — MR. LINCOLIN HENRY CLARK FAODP

Table of content: MR. LINCOLIN HENRY CLARK FAODP (NPI 1760500623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760500623 NPI number — MR. LINCOLIN HENRY CLARK FAODP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
LINCOLIN
Provider Middle Name:
HENRY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FAODP
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:
1760500623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 WHITMORE RD APT A1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48203-1749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-399-3727
Provider Business Mailing Address Fax Number:
313-871-0040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 ALGER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-871-9940
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

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: 101YA0400X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com