Active NPI
Alice Clark
- Child Mental Illness Respite Care
- Florence, AZ
National Provider Identifier
1063589299
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Child Mental Illness Respite Care
- License
- 10784
- Practice address
- 10720 E. Marigold Lane
Florence, AZ 85232 - Phone
- (520) 723-8228
- NPI assigned
- Nov 30, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Child Mental Illness Respite Care | 385HR2055X | 10784 | AZ | Primary |
Addresses
Primary practice location
10720 E. Marigold Lane
Florence, AZ 85232
Mailing address
10720 E. Marigold Lane
Florence, AZ 85232
Phone (520) 723-8228
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 988321 | Other | AZ | AHCCCS ID |
Other names 1
- Ronald Clark
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10784 | AZ | MD | Child Mental Illness Respite Care |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164844800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1063589299",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10720 E. MARIGOLD LANE",
"city": "FLORENCE",
"state": "AZ",
"postal_code": "85232",
"telephone_number": "520-723-8228"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10720 E. MARIGOLD LANE",
"city": "FLORENCE",
"state": "AZ",
"postal_code": "85232",
"telephone_number": "520-723-8228"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "ALICE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-11-30",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "385HR2055X",
"taxonomy_group": "",
"desc": "Respite Care, Respite Care, Mental Illness, Child",
"state": "AZ",
"license": "10784",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AHCCCS ID",
"identifier": "988321",
"state": "AZ"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "RONALD",
"last_name": "CLARK",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Florence, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.