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General NPI Number Information
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NPI Number | 1053893073
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Entity Type | Individual
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Provider Name | KELLY CLARK
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Gender | Male
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Dates
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Enumeration Date | 09/06/2018
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Last Update Date | 09/06/2018
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Provider Practice Location Address
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Address Line | 970 HILLTOP DR
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City | WEATHERFORD
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State | TX
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Zip | 76086-5488
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Country | US
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Telephone | 817-808-1633
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Fax |
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Provider Business Mailing Address
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Address Line | 3025 YUCCA RD
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City | WILLOW PARK
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State | TX
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Zip | 76087-7116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2109081
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License Number State | TX
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