MEDICARE: MARYBETH CLARK MS, RD

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	923323	NV

General Provider Information

NPI Number	:	1780613141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYBETH CLARK MS, RD

Provider Business Mailing Address
First Line	:	6273 DEAN MARTIN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3833
Country	:	US
Telephone Number	:	702-616-1605
Fax Number	:	702-616-0967

Provider Business Practice Location Address
First Line	:	2121 E FLAMINGO RD
Second Line	:	SUITE 114
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5122
Country	:	US
Telephone Number	:	702-382-8841
Fax Number	:	702-369-2370

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	01/11/2008

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