Basic Information
| Provider Information | |||||||||
| NPI: | 1538760418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | LA' BREA | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCDONOUGH ST APT 416 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232242289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027384505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7700 E PARHAM RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232944301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047475600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 173540 | VA | N | 246ZC0007X | 199323 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.