Provider Demographics
NPI:1366089377
Name:CLACK, LIONEL HERBERT
Entity type:Individual
Prefix:
First Name:LIONEL
Middle Name:HERBERT
Last Name:CLACK
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 1:14094 MARICOPA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-9777
Mailing Address - Country:US
Mailing Address - Phone:760-792-1212
Mailing Address - Fax:626-608-2645
Practice Address - Street 1:1161 E COVINA BLVD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1523
Practice Address - Country:US
Practice Address - Phone:626-859-5275
Practice Address - Fax:626-608-2645
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA724717163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse