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General NPI Number Information
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NPI Number | 1558490763
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Entity Type | Organization
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Legal Business Name | STACEY J. CLARKE DPM, PC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1408 N HALL ST
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City | LA GRANDE
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State | OR
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Zip | 97850-3807
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Country | US
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Telephone | 541-963-0265
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Fax | 541-963-6176
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Provider Business Mailing Address
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Address Line | 1408 N HALL ST
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City | LA GRANDE
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State | OR
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Zip | 97850-3807
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Country | US
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Telephone | 541-963-0265
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Fax | 541-963-6176
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Authorized Official
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Title or Position | OWNER
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Name | MRS. STACEY J CLARKE
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Credential | DPM
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Telephone | 541-963-0265
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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 | DP00283
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License Number State | OR
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