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General NPI Number Information
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NPI Number | 1861766321
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Entity Type | Organization
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Legal Business Name | CLARK A GUNDERSON MD AMC
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Dates
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Enumeration Date | 03/01/2012
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Last Update Date | 03/01/2012
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Provider Practice Location Address
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Address Line | 2615 ENTERPRISE BLVD
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7686
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Country | US
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Telephone | 337-439-0385
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Fax | 337-433-5448
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Provider Business Mailing Address
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Address Line | 2615 ENTERPRISE BLVD
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7686
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Country | US
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Telephone | 337-439-0385
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Fax | 337-433-5448
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLARK A GUNDERSON
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Credential | M.D.
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Telephone | 337-439-0385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0124589
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License Number State | LA
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