Healthcare Provider Details

I. General information

NPI: 1477478014
Provider Name (Legal Business Name): TIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 N 20TH ST FL 1
PHILADELPHIA PA
19138-2129
US

IV. Provider business mailing address

7131 N 20TH ST FL 1
PHILADELPHIA PA
19138-2129
US

V. Phone/Fax

Practice location:
  • Phone: 267-444-5214
  • Fax:
Mailing address:
  • Phone: 267-444-5214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCT176272
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: