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General NPI Number Information
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NPI Number | 1114453933
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Entity Type | Individual
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Provider Name | KEITH ANTHONY CLARK
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Gender | Male
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 11311 N CENTRAL EXPY STE 211
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City | DALLAS
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State | TX
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Zip | 75243-6707
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Country | US
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Telephone | 214-315-2959
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 273326
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City | FORT COLLINS
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State | CO
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Zip | 80527-3326
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Country | US
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Telephone | 866-996-2772
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT111749
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License Number State | TX
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