Healthcare Provider Details

I. General information

NPI: 1508175092
Provider Name (Legal Business Name): CLARENCE A STUPPARD SR. ADMINISTRATOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 BRIGHTON ST
PHILADELPHIA PA
19149-1922
US

IV. Provider business mailing address

2924 BRIGHTON ST
PHILADELPHIA PA
19149-1922
US

V. Phone/Fax

Practice location:
  • Phone: 215-624-1321
  • Fax: 215-624-1034
Mailing address:
  • Phone: 215-624-1321
  • Fax: 215-624-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number16713601
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number16713601
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: