Provider Demographics
NPI:1902664022
Name:CLARK, TINA L (LDO2206)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:LDO2206
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-6078
Mailing Address - Country:US
Mailing Address - Phone:678-758-4783
Mailing Address - Fax:
Practice Address - Street 1:557 HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-6078
Practice Address - Country:US
Practice Address - Phone:678-758-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO2206156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician