Provider Demographics
NPI:1619702289
Name:CLARK, CANDIE
Entity type:Individual
Prefix:
First Name:CANDIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 CARROLLTON VILLA RICA HWY STE 301
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5195
Mailing Address - Country:US
Mailing Address - Phone:770-742-9375
Mailing Address - Fax:
Practice Address - Street 1:1836 CARROLLTON VILLA RICA HWY STE 301
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5195
Practice Address - Country:US
Practice Address - Phone:770-742-9375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies