=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144524851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN ALLAN CLARK LRT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2011
-----------------------------------------------------
Last Update Date | 06/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2910 N SAGINAW RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-486-3040
-----------------------------------------------------
Fax | 989-486-3770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2910 N SAGINAW RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-486-3040
-----------------------------------------------------
Fax | 989-486-3770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2278H0200X
-----------------------------------------------------
Taxonomy Name | Home Health Certified Respiratory Therapist
-----------------------------------------------------
License Number | L1645896
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------