Provider Demographics
NPI:1417744863
Name:CLARK, GARY MICHAEL JESUS (CHW)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL JESUS
Last Name:CLARK
Suffix:
Gender:
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8151 ARLINGTON AVE STE U-V
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-0436
Mailing Address - Country:US
Mailing Address - Phone:951-688-3001
Mailing Address - Fax:
Practice Address - Street 1:8151 ARLINGTON AVE STE U-V
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-0436
Practice Address - Country:US
Practice Address - Phone:951-688-3001
Practice Address - Fax:951-688-3022
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker