Clark, Gregory Alexander

Clark, Gregory Alexander is an individual health care provider with primary practice located at 12547 Riverdale Blvd Nw Costco Optical Department, Coon Rapids MN 55448-6708. He recently has only one registered license in Eye and Vision Services Providers / Optometrist, which is considered as his primary health care specialty. Clark, Gregory Alexander can be contacted via phone (763) 712-7761.

Contact Information

Primary practice address
12547 Riverdale Blvd Nw Costco Optical Department Coon Rapids MN 55448-6708
Phone: (763) 712-7761
Fax: (763) 712-7787
Website:
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Health care specialties

SpecialtyCodeLicense #State
Eye and Vision Services Providers / Optometrist 152W00000X 2806 Minnesota

Profile Details

NPI number 1467521153
LBN Legal business name Clark, Gregory Alexander
Credentials Doctor of Optometry (OD)
Entity Individual
Sole proprietor 1 No
Enumeration date Nov 7th, 2006
Last updated Nov 29th, 2012 - about 12 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1467521153 NPPES
Minnesota MEDICAID 163474700

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