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General NPI Number Information
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NPI Number | 1053109280
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Entity Type | Individual
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Provider Name | ZACHARY CLARK
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Gender | Male
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Dates
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Enumeration Date | 04/28/2025
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 123 W MONDAMIN ST
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City | MINOOKA
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State | IL
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Zip | 60447-9191
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Country | US
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Telephone | 815-255-2888
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Fax |
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Provider Business Mailing Address
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Address Line | 414 GRANDE DR UNIT A
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City | MINOOKA
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State | IL
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Zip | 60447-9024
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Country | US
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Telephone | 815-260-7613
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 237700000X
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Taxonomy Name | Hearing Instrument Specialist
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License Number |
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License Number State |
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