Organization
GREGORY CLARK, O.D., INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GREGORY ALEXANDER CLARK O.D. (OWNER)
(612) 703-0298
Entity
Organization
Contact information
Practice address
12547 RIVERDALE BLVD NW, COSTCO OPTICAL DEPARTMENT, COON RAPIDS, MN 55448-6708
(763) 712-7761
(763) 712-7787
Mailing address
16160 22ND PL N, PLYMOUTH, MN 55447-2382
(612) 703-0298
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2806
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1634747-00
—
MN
Enumeration date
11/07/2006
Last updated
11/29/2012
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