Healthcare Provider Details

I. General information

NPI: 1225970940
Provider Name (Legal Business Name): CLARK COMMUNITY DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 S WESTERN AVE
LOS ANGELES CA
90047-1812
US

IV. Provider business mailing address

4465 WAWONA ST
LOS ANGELES CA
90065-5133
US

V. Phone/Fax

Practice location:
  • Phone: 323-310-6381
  • Fax:
Mailing address:
  • Phone: 323-310-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ADRIAN TAFOYA
Title or Position: CONSULTANT / CLINICAL DIRECTOR
Credential: LCSW
Phone: 310-866-6703