Healthcare Provider Details

I. General information

NPI: 1679173710
Provider Name (Legal Business Name): ERIC DEON CLARK SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 TURK ST
SAN FRANCISCO CA
94102-3329
US

IV. Provider business mailing address

433 TURK ST
SAN FRANCISCO CA
94102-3329
US

V. Phone/Fax

Practice location:
  • Phone: 415-928-7800
  • Fax: 415-928-3710
Mailing address:
  • Phone: 415-928-7800
  • Fax: 415-928-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: