Healthcare Provider Details

I. General information

NPI: 1891740478
Provider Name (Legal Business Name): GRENVILLE CLARK M.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

18 MEDICAL PARK DR
ASHEVILLE NC
28803-2493
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-1900
  • Fax: 757-467-7900
Mailing address:
  • Phone: 828-785-4700
  • Fax: 828-552-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP11167
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305202681
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: