MEDICARE: RENITA CLARK LPN

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	164W00000X	Licensed Practical Nurse	PN126160	OH
2	164W00000X	Licensed Practical Nurse	3085432	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184872442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENITA CLARK LPN

Provider Business Mailing Address
First Line	:	12940 FAIRHILL RD
Second Line	:	STE 71
City	:	SHAKER HTS
State	:	OH
Zip	:	44120-5525
Country	:	US
Telephone Number	:	216-904-8623
Fax Number	:

Provider Business Practice Location Address
First Line	:	12940 FAIRHILL RD
Second Line	:	STE 71
City	:	SHAKER HTS
State	:	OH
Zip	:	44120-5525
Country	:	US
Telephone Number	:	216-904-8623
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	06/22/2011

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