Healthcare Provider Details

I. General information

NPI: 1659355121
Provider Name (Legal Business Name): RICHARD D CLARK RN ARNP CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18221 TORRENCE AVE
LANSING IL
60438-2870
US

IV. Provider business mailing address

18221 TORRENCE AVE
LANSING IL
60438-2870
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-9450
  • Fax:
Mailing address:
  • Phone: 708-895-9408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1484659051
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number134677
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number54725
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54725
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number134677
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number09.006191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: