1467829911 NPI number — MS. CRYSTAL LYNN CLARK MS, ATC

Table of content: MS. CRYSTAL LYNN CLARK MS, ATC (NPI 1467829911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467829911 NPI number — MS. CRYSTAL LYNN CLARK MS, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CRYSTAL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC
Provider Gender Code:
F

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:
1467829911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 BROADRICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-2504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-395-9716
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 MANLEY ST
Provider Second Line Business Practice Location Address:
DALTON HIGH SCHOOL
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30720-4088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-395-9716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2015

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: 2255A2300X , with the licence number:  AT002055 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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