Healthcare Provider Details

I. General information

NPI: 1407308018
Provider Name (Legal Business Name): TYLER CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2016
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 KESWICK PL
SAINT LOUIS MO
63119
US

IV. Provider business mailing address

1900 MCNATT DR APT 1
BROOKLAND AR
72417-9024
US

V. Phone/Fax

Practice location:
  • Phone: 573-344-7009
  • Fax:
Mailing address:
  • Phone: 573-344-7009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: