MEDICARE: LATRICE CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	HCO-202031	VA
2	3747P1801X	Personal Care Attendant	HCO-202031	VA
3	376J00000X	Homemaker	HCO-202031	VA
4	376K00000X	Nurse's Aide	HCO-202031	VA
5	253Z00000X	In Home Supportive Care Agency	HCO-202031	VA

General Provider Information

NPI Number	:	1043855687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRICE CLARK

Provider Business Mailing Address
First Line	:	5226 WHETSTONE RD
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-4324
Country	:	US
Telephone Number	:	336-866-9248
Fax Number	:

Provider Business Practice Location Address
First Line	:	5226 WHETSTONE RD
Second Line	:
City	:	N CHESTERFLD
State	:	VA
Zip	:	23234-4324
Country	:	US
Telephone Number	:	336-866-9248
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	11/07/2019

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