Healthcare Provider Details

I. General information

NPI: 1790505154
Provider Name (Legal Business Name): MR. JAMES ROBERT CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 ROSCOE BLVD SUITE 400
PANORAMA CITY CA
91402
US

IV. Provider business mailing address

14500 ROSCOE BLVD SUITE 400
PANORAMA CITY CA
91402
US

V. Phone/Fax

Practice location:
  • Phone: 818-741-2906
  • Fax:
Mailing address:
  • Phone: 818-741-2906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: