MEDICARE: MS. VIRLA BEATRICE CLARK C.R.N.A.

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	261QA1903X	Ambulatory Surgical Clinic/Center	723	CA
2	367500000X	Certified Registered Nurse Anesthetist	723	CA

General Provider Information

NPI Number	:	1255577516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIRLA BEATRICE CLARK C.R.N.A.

Provider Business Mailing Address
First Line	:	30260 RANCHO VIEJO RD
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1561
Country	:	US
Telephone Number	:	949-661-1700
Fax Number	:

Provider Business Practice Location Address
First Line	:	30260 RANCHO VIEJO RD
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1561
Country	:	US
Telephone Number	:	949-661-1700
Fax Number	:

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

Provider Enumeration Date	:	12/16/2008
Last Update Date	:	12/16/2008

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