MEDICARE: MR. CHAD ALAN CLARK MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5835	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083617906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHAD ALAN CLARK MSPT

Provider Business Mailing Address
First Line	:	58 GLENROYAL DR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81005-2174
Country	:	US
Telephone Number	:	719-565-6678
Fax Number	:	719-561-0577

Provider Business Practice Location Address
First Line	:	58 GLENROYAL DR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81005-2174
Country	:	US
Telephone Number	:	719-565-6678
Fax Number	:	719-561-0577

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/01/2011

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