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General NPI Number Information
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NPI Number | 1962945675
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Entity Type | Individual
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Provider Name | MRS. ANN MARIE MONICA CLARK
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Gender | Female
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Dates
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Enumeration Date | 11/29/2016
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Last Update Date | 11/29/2016
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Provider Practice Location Address
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Address Line | 3524 ACACIA AVENUE
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City | SAN BERNARDINO
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State | CA
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Zip | 92405
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Country | US
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Telephone | 909-352-6701
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Fax |
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Provider Business Mailing Address
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Address Line | 1651 N. RIVERSIDE AVE #124
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City | RIALTO
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State | CA
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Zip | 92376
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Country | US
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Telephone | 909-528-7061
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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 | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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