Provider Demographics
NPI:1699476465
Name:CLARK, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 W BUCKEYE ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:OH
Mailing Address - Zip Code:43410-1938
Mailing Address - Country:US
Mailing Address - Phone:419-680-8252
Mailing Address - Fax:
Practice Address - Street 1:328 W BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-1938
Practice Address - Country:US
Practice Address - Phone:419-680-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health