Healthcare Provider Details

I. General information

NPI: 1376460907
Provider Name (Legal Business Name): JOSEPH CLARK MS, RD, CSSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOE CLARK

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 W NORTH SHORE AVE APT 2
CHICAGO IL
60645-5048
US

IV. Provider business mailing address

2508 W NORTH SHORE AVE APT 2
CHICAGO IL
60645-5048
US

V. Phone/Fax

Practice location:
  • Phone: 651-756-0081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: