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General NPI Number Information
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NPI Number | 1487206439
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Entity Type | Individual
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Provider Name | AMBER CLARK
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Gender | Female
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Dates
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Enumeration Date | 07/10/2019
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Last Update Date | 07/10/2019
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Provider Practice Location Address
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Address Line | 12182 HIGHWAY 92
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City | WOODSTOCK
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State | GA
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Zip | 30188-4885
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Country | US
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Telephone | 770-516-4719
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Fax |
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Provider Business Mailing Address
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Address Line | 2759 NORTHGATE CT NW
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City | ACWORTH
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State | GA
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Zip | 30101-6898
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Country | US
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Telephone |
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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 | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | OPT003176
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT003176
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License Number State | GA
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