Provider Demographics
NPI:1215700745
Name:CLARK, KEVIN EUGENE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EUGENE
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 1:87 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2910
Mailing Address - Country:US
Mailing Address - Phone:304-813-3668
Mailing Address - Fax:
Practice Address - Street 1:87 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2910
Practice Address - Country:US
Practice Address - Phone:304-813-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant