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General NPI Number Information
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NPI Number | 1972693497
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Entity Type | Individual
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Provider Name | DALLAS LAYNE CLARK P.T.
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Gender | Male
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 20 ADAVILLE DRIVE SUITE 10
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City | DIAMONDVILLE
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State | WY
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Zip | 83116
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Country | US
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Telephone | 307-877-1000
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Fax | 307-877-1000
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Provider Business Mailing Address
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Address Line | PO BOX 152
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City | LAKETOWN
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State | UT
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Zip | 84038-0152
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Country | US
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Telephone | 435-946-3512
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Fax | 435-946-2311
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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 | 6293691-2401
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 802
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License Number State | WY
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