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General NPI Number Information
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NPI Number | 1649398769
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Entity Type | Organization
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Legal Business Name | ALYCE D. CLARK
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 10640 HOLMES ROAD
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City | KANSAS CITY
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State | MO
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Zip | 64131-3404
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Country | US
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Telephone | 816-943-1300
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Fax | 816-942-7443
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Provider Business Mailing Address
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Address Line | 10640 HOLMES RD
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City | KANSAS CITY
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State | MO
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Zip | 64131-3404
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Country | US
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Telephone | 816-943-1300
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Fax | 816-942-7443
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ALYCE DENISE CLARK
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Credential | RN, BSN
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Telephone | 816-943-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 856274402
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License Number State | MO
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