1538708755 NPI number — JACOB LARK DPT

Table of content: JACOB LARK DPT (NPI 1538708755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538708755 NPI number — JACOB LARK DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARK
Provider First Name:
JACOB
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538708755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13171 MARINER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH ROYALTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44133-5980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-879-6266
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4766 BELPAR ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-244-1001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT018124 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X , with the licence number: 297919 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 018124 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)