Provider Demographics
NPI:1386497964
Name:CLARK, CORNELIUS
Entity type:Individual
Prefix:
First Name:CORNELIUS
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 1:414 CROCUS PL
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-4216
Mailing Address - Country:US
Mailing Address - Phone:330-819-4119
Mailing Address - Fax:
Practice Address - Street 1:414 CROCUS PL
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4216
Practice Address - Country:US
Practice Address - Phone:330-819-4119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker