MEDICARE: DEMETRIA CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	343900000X	Non-emergency Medical Transport (VAN)
2	251E00000X	Home Health Agency
3	343800000X	Secured Medical Transport (VAN)
4	247200000X	Other Technician
5	261QA0600X	Adult Day Care Clinic/Center
6	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
7	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1487209722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRIA CLARK

Provider Business Mailing Address
First Line	:	709 LODGE AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-1173
Country	:	US
Telephone Number	:	567-702-1078
Fax Number	:

Provider Business Practice Location Address
First Line	:	709 LODGE AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-2915
Country	:	US
Telephone Number	:	567-702-1078
Fax Number	:

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

Provider Enumeration Date	:	08/05/2019
Last Update Date	:	10/02/2022

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Directions to “ DEMETRIA CLARK ” Practice Location

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