Individual
BENJAMIN JACOB CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
600 EAST BLVD, ELKHART, IN 46514-2483
(574) 523-3193
Mailing address
14660 CARRIGAN CT, GRANGER, IN 46530-4222
(574) 523-3193
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
28193318A
IN
Other
Enumeration date
12/22/2010
Last updated
12/22/2010
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