MEDICARE: CLARK EYECARE, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1528	AZ

General Provider Information

NPI Number	:	1003030974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK EYECARE, P.C.

Provider Business Mailing Address
First Line	:	2548 MAJESTIC WAY
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-8767
Country	:	US
Telephone Number	:	928-754-3714
Fax Number	:	928-758-1683

Provider Business Practice Location Address
First Line	:	2840 HIGHWAY 95
Second Line	:	WALMART VISION CENTER SUITE 505
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7792
Country	:	US
Telephone Number	:	928-758-1524
Fax Number	:	928-758-1683

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. CHRISTOPHER N CLARK
Credential	:	O.D.
Telephone Number	:	928-754-3714

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	11/04/2011

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