Provider Demographics
NPI:1730796202
Name:CLARK JR, HULEN FRANK
Entity type:Individual
Prefix:MR
First Name:HULEN
Middle Name:FRANK
Last Name:CLARK JR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 FOURTH AVENUE, LOT 62
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2893
Mailing Address - Country:US
Mailing Address - Phone:606-492-4076
Mailing Address - Fax:
Practice Address - Street 1:1001 FOURTH AVENUE, LOT 62
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-2893
Practice Address - Country:US
Practice Address - Phone:606-492-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0374212Medicaid