Individual
DESIRAE CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5100 LYDIA AVE, KANSAS CITY, MO 64110-2608
(826) 749-9147
Mailing address
PO BOX 300564, KANSAS CITY, MO 64130-0564
(816) 749-9147
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Enumeration date
08/21/2019
Last updated
08/21/2019
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