MEDICARE: NICOLE CLARK LDO

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	156FX1800X	Optician	527	NV

General Provider Information

NPI Number	:	1902699499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CLARK LDO

Provider Business Mailing Address
First Line	:	8137 REDBUD VINE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-4456
Country	:	US
Telephone Number	:	707-758-3386
Fax Number	:

Provider Business Practice Location Address
First Line	:	3950 W LAKE MEAD BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4895
Country	:	US
Telephone Number	:	702-631-8472
Fax Number	:	702-631-9417

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

Provider Enumeration Date	:	05/27/2025
Last Update Date	:	05/27/2025

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Directions to “ NICOLE CLARK LDO” Practice Location

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