Provider Demographics
NPI:1063981900
Name:CLARK OPTOMETRIC CENTER OF SC, P.A.
Entity type:Organization
Organization Name:CLARK OPTOMETRIC CENTER OF SC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-544-4097
Mailing Address - Street 1:200 PERIMETER PARK DRIVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560
Mailing Address - Country:US
Mailing Address - Phone:919-544-4097
Mailing Address - Fax:919-678-3814
Practice Address - Street 1:419 SE MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2676
Practice Address - Country:US
Practice Address - Phone:864-417-2345
Practice Address - Fax:864-399-4519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty