Provider Demographics
NPI:1558192252
Name:CLARK, ALLEN IV
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:CLARK
Suffix:IV
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 1:12360 RICHMOND AVE APT 915
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2451
Mailing Address - Country:US
Mailing Address - Phone:702-515-9048
Mailing Address - Fax:
Practice Address - Street 1:12360 RICHMOND AVE APT 915
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2451
Practice Address - Country:US
Practice Address - Phone:702-515-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker