1790850758 NPI number — MR. TODD K A CLARK MSPT

Table of content: MR. TODD K A CLARK MSPT (NPI 1790850758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790850758 NPI number — MR. TODD K A CLARK MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
TODD
Provider Middle Name:
K A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1790850758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KAILUA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96734-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-262-2292
Provider Business Mailing Address Fax Number:
808-262-2293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1090 KEOLU DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
KAILUA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96734-3871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-262-2292
Provider Business Practice Location Address Fax Number:
808-262-2293
Provider Enumeration Date:
11/22/2006

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: 225100000X , with the licence number:  1978 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT1978 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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