1629140173 NPI number — GARY W. CLARK INC

Table of content: (NPI 1629140173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629140173 NPI number — GARY W. CLARK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY W. CLARK INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GARY W CLARK DPM A PROFESSIONAL CORP
Provider Other Organization Name Type Code:
3
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:
1629140173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1986
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84721-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-867-8521
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 W 1325 N
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CEDAR CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84720-7792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-867-8521
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
435-867-8521

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  320729-0501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X , with the licence number: 3207290501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 529212733004 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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