Healthcare Provider Details

I. General information

NPI: 1578163549
Provider Name (Legal Business Name): MRS. CHARLOTTE S. CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66450 KIRKWOOD HEIGHTS RD
BELLAIRE OH
43906
US

IV. Provider business mailing address

66450 KIRKWOOD HEIGHTS RD
BELLAIRE OH
43906
US

V. Phone/Fax

Practice location:
  • Phone: 740-359-1698
  • Fax:
Mailing address:
  • Phone: 740-359-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: