Healthcare Provider Details

I. General information

NPI: 1063939817
Provider Name (Legal Business Name): RANDY GENE CLARK SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 BRUCE SMITH PKWY
WEST PLAINS MO
65775-7691
US

IV. Provider business mailing address

45335 SIERRA HWY
LANCASTER CA
93534-1611
US

V. Phone/Fax

Practice location:
  • Phone: 417-308-0671
  • Fax:
Mailing address:
  • Phone: 661-949-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number202404464
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: