MEDICARE: NANCY COPPIC CLARK OD

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	152W00000X	Optometrist	0618000028	VA

General Provider Information

NPI Number	:	1447218524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NANCY COPPIC CLARK OD

Provider Business Mailing Address
First Line	:	123 DEER RUN RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-2863
Country	:	US
Telephone Number	:	434-793-6912
Fax Number	:	434-799-8641

Provider Business Practice Location Address
First Line	:	123 DEER RUN RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-2863
Country	:	US
Telephone Number	:	434-793-6912
Fax Number	:	434-799-8641

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NANCY COPPIC CLARK
Credential	:	O.D.
Telephone Number	:	434-793-6912

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	10/16/2008

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