Provider Demographics
NPI:1194315077
Name:CLARK, CURTIS ALLEN
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 MILLSTONE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OH
Mailing Address - Zip Code:45613-9493
Mailing Address - Country:US
Mailing Address - Phone:740-708-2950
Mailing Address - Fax:
Practice Address - Street 1:1124 MILLSTONE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OH
Practice Address - Zip Code:45613-9493
Practice Address - Country:US
Practice Address - Phone:740-708-2950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3094842Medicaid