MEDICARE: MICHELLE CLARKE

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	174400000X	Specialist	960001093	CA

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	:	1245765791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE CLARKE

Provider Business Mailing Address
First Line	:	441 N CENTRAL AVE
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91786-4219
Country	:	US
Telephone Number	:	909-240-7680
Fax Number	:	909-981-0296

Provider Business Practice Location Address
First Line	:	8141 TROOST AVE
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91605-1627
Country	:	US
Telephone Number	:	818-767-3618
Fax Number	:	909-981-0296

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

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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Directions to “ MICHELLE CLARKE ” Practice Location

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