MEDICARE: CLARK HOME RESPIRATORY SUPPLY INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1316945553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK HOME RESPIRATORY SUPPLY INC

Provider Business Mailing Address
First Line	:	168 JEFFERSON HTS
Second Line	:
City	:	CATSKILL
State	:	NY
Zip	:	12414-1215
Country	:	US
Telephone Number	:	518-943-3456
Fax Number	:	518-943-2053

Provider Business Practice Location Address
First Line	:	168 JEFFERSON HTS
Second Line	:
City	:	CATSKILL
State	:	NY
Zip	:	12414-1215
Country	:	US
Telephone Number	:	518-943-3456
Fax Number	:	518-943-2053

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES L CLARK JR.
Credential	:
Telephone Number	:	518-943-3456

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	03/26/2009

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