Healthcare Provider Details

I. General information

NPI: 1184528549
Provider Name (Legal Business Name): MACERIO CLARK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 3RD AVE SUITE 116
SEATTLE WA
98121
US

IV. Provider business mailing address

5301 TALBOT RD Q102
RENTON WA
98055
US

V. Phone/Fax

Practice location:
  • Phone: 206-240-1804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: