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General NPI Number Information
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NPI Number | 1114192820
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Entity Type | Individual
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Provider Name | TONY ALLEN CLARK M.P.T.
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Gender | Male
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 04/23/2008
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Provider Practice Location Address
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Address Line | 4251 W CEMETERY RD
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City | CANYON
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State | TX
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Zip | 79015-8226
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Country | US
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Telephone | 806-655-7960
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1103
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City | CANYON
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State | TX
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Zip | 79015-1103
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Country | US
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Telephone | 806-655-7960
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1124832
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License Number State | TX
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