MEDICARE: MARK CLARK

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	372500000X	Chore Provider	NE
2	372600000X	Adult Companion
3	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1205722303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK CLARK

Provider Business Mailing Address
First Line	:	7601 N 58TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68152-2332
Country	:	US
Telephone Number	:	531-239-2352
Fax Number	:

Provider Business Practice Location Address
First Line	:	7601 N 58TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68152-2332
Country	:	US
Telephone Number	:	531-239-2352
Fax Number	:

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

Provider Enumeration Date	:	06/16/2025
Last Update Date	:	06/16/2025

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Directions to “ MARK CLARK ” Practice Location

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