Provider Demographics
NPI:1245792332
Name:CLARK, LARIN TIMOTHY (IDMT, LPN)
Entity type:Individual
Prefix:MR
First Name:LARIN
Middle Name:TIMOTHY
Last Name:CLARK
Suffix:
Gender:M
Credentials:IDMT, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 CURTISS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2425
Mailing Address - Country:US
Mailing Address - Phone:318-456-6555
Mailing Address - Fax:
Practice Address - Street 1:243 CURTISS RD STE 100
Practice Address - Street 2:
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2425
Practice Address - Country:US
Practice Address - Phone:318-456-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X
LA0002105974164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No164W00000XNursing Service ProvidersLicensed Practical Nurse