Provider Demographics
NPI:1750081170
Name:CLARK, SCOTT SR
Entity type:Individual
Prefix:
First Name:SCOTT
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 1:440 MONTICELLO AVE STE 1802
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2670
Mailing Address - Country:US
Mailing Address - Phone:800-323-0024
Mailing Address - Fax:804-701-3033
Practice Address - Street 1:2900 LAKETREE CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-5232
Practice Address - Country:US
Practice Address - Phone:800-323-0024
Practice Address - Fax:804-701-3033
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA114688083747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant