Provider Demographics
NPI:1366175374
Name:CLARK, CHARLES EDWARD
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
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 1:3812 LIBERTY HWY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1344
Mailing Address - Country:US
Mailing Address - Phone:864-225-2800
Mailing Address - Fax:
Practice Address - Street 1:3812 LIBERTY HWY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1344
Practice Address - Country:US
Practice Address - Phone:864-225-2800
Practice Address - Fax:864-225-6444
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC343156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty