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General NPI Number Information
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NPI Number | 1619704178
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Entity Type | Individual
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Provider Name | CHANDLER CLARK PTA
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Gender | Male
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Dates
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Enumeration Date | 09/18/2024
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Last Update Date | 09/18/2024
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Provider Practice Location Address
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Address Line | 3100 OLYMPUS BLVD STE 500
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City | COPPELL
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State | TX
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Zip | 75019-5473
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Country | US
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Telephone | 214-442-4329
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Fax |
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Provider Business Mailing Address
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Address Line | 5401 HOLLYTREE DR APT 3002
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City | TYLER
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State | TX
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Zip | 75703-3486
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Country | US
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Telephone | 903-520-0593
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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 | 2182964
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License Number State | TX
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