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General NPI Number Information
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NPI Number | 1477213619
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Entity Type | Individual
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Provider Name | MS. CRYSTAL CLARK
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Gender | Female
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Dates
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Enumeration Date | 12/29/2021
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Last Update Date | 12/29/2021
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Provider Practice Location Address
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Address Line | 3700 S MAIN ST
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City | BLACKSBURG
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State | VA
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Zip | 24060-7017
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Country | US
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Telephone | 540-951-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 506 ESSEX CT # 1
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City | BLACKSBURG
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State | VA
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Zip | 24060-6464
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Country | US
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Telephone | 804-429-7185
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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 | 172A00000X
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Taxonomy Name | Driver
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License Number | A69874069
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License Number State | VA
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