1992053474 NPI number — MR. CHRISTOPHER TAD CLARK M.ED.

Table of content: MR. CHRISTOPHER TAD CLARK M.ED. (NPI 1992053474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992053474 NPI number — MR. CHRISTOPHER TAD CLARK M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CHRISTOPHER
Provider Middle Name:
TAD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.ED.
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:
1992053474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 DEWAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82901-6218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-382-3010
Provider Business Mailing Address Fax Number:
307-382-6881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1471 DEWAR DR STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-630-3466
Provider Business Practice Location Address Fax Number:
307-316-0228
Provider Enumeration Date:
08/15/2012

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: 101YM0800X , with the licence number:  LPC-1198 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 1198 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com