Healthcare Provider Details

I. General information

NPI: 1659090272
Provider Name (Legal Business Name): ALICE BRYCE CLARK MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 COUNTRY OAKS LN
THOUSAND OAKS CA
91362-1900
US

IV. Provider business mailing address

1748 COUNTRY OAKS LN
THOUSAND OAKS CA
91362-1900
US

V. Phone/Fax

Practice location:
  • Phone: 206-898-0453
  • Fax:
Mailing address:
  • Phone: 206-898-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86035426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: