MEDICARE: TARA 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	172V00000X	Community Health Worker	3814	OH

General Provider Information

NPI Number	:	1356731186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA CLARK

Provider Business Mailing Address
First Line	:	540 GREAT OAKS TRL
Second Line	:
City	:	WADSWORTH
State	:	OH
Zip	:	44281-8799
Country	:	US
Telephone Number	:	330-336-1141
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 GRILL RD
Second Line	:
City	:	NEW FRANKLIN
State	:	OH
Zip	:	44216-9320
Country	:	US
Telephone Number	:	330-329-4408
Fax Number	:

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

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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Directions to “ TARA CLARK ” Practice Location

Language	Start Address	Practice Location

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