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General NPI Number Information
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NPI Number | 1053319673
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Entity Type | Individual
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Provider Name | JODI LYNN CLARK O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/08/2005
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 17001 HAWTHORNE BLVD SUITE B
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City | LAWNDALE
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State | CA
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Zip | 90260-3302
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Country | US
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Telephone | 310-370-3360
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Fax | 310-370-6227
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Provider Business Mailing Address
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Address Line | 202 VIA MESA GRANDE
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City | REDONDO BEACH
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State | CA
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Zip | 90277-6639
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Country | US
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Telephone | 310-373-1624
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 9934T
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License Number State | CA
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