Provider Demographics
NPI:1689226805
Name:CLARK, TIFFANY RENEE (SMALL BUSINESS OWNER)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:SMALL BUSINESS OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0034
Mailing Address - Country:US
Mailing Address - Phone:225-268-5939
Mailing Address - Fax:
Practice Address - Street 1:6632 OAKS EDGE DR
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-3259
Practice Address - Country:US
Practice Address - Phone:225-268-5939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care