Provider Demographics
NPI:1962945675
Name:CLARK, ANN MARIE MONICA
Entity type:Individual
Prefix:MRS
First Name:ANN MARIE
Middle Name:MONICA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANN MARIE
Other - Middle Name:MONICA
Other - Last Name:LORING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1651 N. RIVERSIDE AVE
Mailing Address - Street 2:#124
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376
Mailing Address - Country:US
Mailing Address - Phone:909-528-7061
Mailing Address - Fax:
Practice Address - Street 1:3524 ACACIA AVENUE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405
Practice Address - Country:US
Practice Address - Phone:909-352-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness