Provider Demographics
NPI:1386238764
Name:CLARK, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:59 TOWNSHIP ROAD 1419 # 2
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-8816
Mailing Address - Country:US
Mailing Address - Phone:681-888-1003
Mailing Address - Fax:
Practice Address - Street 1:59 TOWNSHIP ROAD 1419 # 2
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8816
Practice Address - Country:US
Practice Address - Phone:681-888-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker