MEDICARE: ROSE L CLARK

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	225700000X	Massage Therapist	MA62209	FL

General Provider Information

NPI Number	:	1316779945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE L CLARK

Provider Business Mailing Address
First Line	:	641 W FAIRBANKS AVE STE 218
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-4770
Country	:	US
Telephone Number	:	689-986-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	641 W FAIRBANKS AVE STE 218
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-4770
Country	:	US
Telephone Number	:	689-986-5100
Fax Number	:

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

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	08/14/2024

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