=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760191274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW HUNTER CLARK DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2022
-----------------------------------------------------
Last Update Date | 11/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 JEFFERSON ST
-----------------------------------------------------
City | DELANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93215-2296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-558-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10707 LEIGH ELLEN AVE
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70810-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-348-2413
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 11229
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------