MEDICARE: FARRAH 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	174400000X	Specialist

General Provider Information

NPI Number	:	1538686167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARRAH CLARK

Provider Business Mailing Address
First Line	:	891 BELSLY BLVD
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-5055
Country	:	US
Telephone Number	:	218-287-4338
Fax Number	:	218-287-5928

Provider Business Practice Location Address
First Line	:	1104 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-844-6853
Fax Number	:	866-226-6130

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

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	04/04/2020

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Directions to “ FARRAH CLARK ” Practice Location

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