1154386183 NPI number — MR. JEFFREY L CLARK LAT, ATC, RET.

Table of content: MR. JEFFREY L CLARK LAT, ATC, RET. (NPI 1154386183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154386183 NPI number — MR. JEFFREY L CLARK LAT, ATC, RET.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JEFFREY
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC, RET.
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:
1154386183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9917 LAKEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE VILLAGE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76227-5427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-417-8280
Provider Business Mailing Address Fax Number:
940-440-0781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2414 W UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75071-2810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-569-9050
Provider Business Practice Location Address Fax Number:
972-569-9076
Provider Enumeration Date:
04/20/2006

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: 174400000X , with the licence number:  AT0438 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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