Provider Demographics
NPI:1174373252
Name:CLARK, KENNY SR
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
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 1:11811 SHAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1931
Mailing Address - Country:US
Mailing Address - Phone:216-584-8564
Mailing Address - Fax:
Practice Address - Street 1:3686 INGLESIDE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5056
Practice Address - Country:US
Practice Address - Phone:216-816-8129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver