Provider Demographics
NPI:1053912451
Name:CLARK, PHILLIP DOUGLAS SR
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DOUGLAS
Last Name:CLARK
Suffix:SR
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 1:3988 TYBRE CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-8483
Mailing Address - Country:US
Mailing Address - Phone:843-353-8664
Mailing Address - Fax:
Practice Address - Street 1:2126 HIGHWAY 9 E UNIT 5B
Practice Address - Street 2:
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568-5725
Practice Address - Country:US
Practice Address - Phone:843-353-8664
Practice Address - Fax:843-485-0047
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1264374U00000X
SC1264374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104613648OtherDRIVER LICENSE