MEDICARE: MRS. RITA T CLARK P.T.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1077-019	WI

General Provider Information

NPI Number	:	1891914891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RITA T CLARK P.T.A.

Provider Business Mailing Address
First Line	:	2061 S 72ND ST
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53219-1208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1834 W WISCONSIN AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53233-2125
Country	:	US
Telephone Number	:	414-933-9813
Fax Number	:	414-933-1522

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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