Healthcare Provider Details

I. General information

NPI: 1225430879
Provider Name (Legal Business Name): CLARK LACHCIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 W HIBISCUS BLVD SUITE 215
MELBOURNE FL
32901-2620
US

IV. Provider business mailing address

1470 PARADISE CT
MERRITT ISLAND FL
32952-5560
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax:
Mailing address:
  • Phone: 321-446-0689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108265
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: