MEDICARE: VIRGINIA 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1760628382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA CLARK

Provider Business Mailing Address
First Line	:	6808 SAMPSON LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-4031
Country	:	US
Telephone Number	:	513-793-2543
Fax Number	:

Provider Business Practice Location Address
First Line	:	6808 SAMPSON LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-4031
Country	:	US
Telephone Number	:	513-793-2543
Fax Number	:

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

Provider Enumeration Date	:	01/02/2009
Last Update Date	:	07/09/2010

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Directions to “ VIRGINIA CLARK ” Practice Location

Language	Start Address	Practice Location

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