Healthcare Provider Details

I. General information

NPI: 1437272085
Provider Name (Legal Business Name): CLARKS RESIDENTIAL CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 CLARK RD
HYDE PARK VT
05655-9218
US

IV. Provider business mailing address

213 CLARK RD
HYDE PARK VT
05655-9218
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-1700
  • Fax: 802-888-9944
Mailing address:
  • Phone: 802-888-1700
  • Fax: 802-888-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0370
License Number StateVT

VIII. Authorized Official

Name: MRS. LINDA E CLARK
Title or Position: OWNER
Credential:
Phone: 802-888-1700