MEDICARE: BETTY 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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1184367914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY CLARK

Provider Business Mailing Address
First Line	:	1353 GLEN OAK PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3859
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1353 GLEN OAK PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3859
Country	:	US
Telephone Number	:	318-404-8644
Fax Number	:

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

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	04/19/2022

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