MEDICARE: CLARK SIMCOE RDN

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1487355798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARK SIMCOE RDN

Provider Business Mailing Address
First Line	:	729 COLLIERSTOWN RD
Second Line	:
City	:	LEXINGTON
State	:	VA
Zip	:	24450-7230
Country	:	US
Telephone Number	:	225-485-0066
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 W WASHINGTON ST
Second Line	:
City	:	LEXINGTON
State	:	VA
Zip	:	24450-2116
Country	:	US
Telephone Number	:	225-485-0066
Fax Number	:

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

Provider Enumeration Date	:	03/14/2023
Last Update Date	:	03/14/2023

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