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General NPI Number Information
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NPI Number | 1023174273
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Entity Type | Organization
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Legal Business Name | EDITH CLARK DPM PLLC
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 06/10/2010
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Provider Practice Location Address
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Address Line | 125 DWYER ST
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City | CLARE
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State | MI
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Zip | 48617-1002
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Country | US
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Telephone | 989-386-9721
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Fax |
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Provider Business Mailing Address
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Address Line | 4310 LEONARD ST NW SUITE 103
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City | WALKER
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State | MI
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Zip | 49534-8447
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Country | US
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Telephone | 616-453-6329
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Fax | 616-453-1725
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Authorized Official
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Title or Position | PHYSICIAN
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Name | EDITH CLARK
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Credential | DPM
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Telephone | 989-386-9721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | EC001742
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License Number State | MI
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