Healthcare Provider Details

I. General information

NPI: 1154396828
Provider Name (Legal Business Name): CLARK DAVID BURTON M.A., A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 E 23RD AVE
HUTCHINSON KS
67502-1106
US

IV. Provider business mailing address

1709 E 24TH AVE APT. #A
HUTCHINSON KS
67502-1148
US

V. Phone/Fax

Practice location:
  • Phone: 620-662-2811
  • Fax:
Mailing address:
  • Phone: 316-706-8896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00499
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: