MEDICARE: ALISHA SUE CLARK

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	172M00000X	Mechanotherapist	19278	OR

General Provider Information

NPI Number	:	1184968760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISHA SUE CLARK

Provider Business Mailing Address
First Line	:	4385 SATTER PL NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97305-4107
Country	:	US
Telephone Number	:	503-812-1280
Fax Number	:

Provider Business Practice Location Address
First Line	:	4385 SATTER PL NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97305-4107
Country	:	US
Telephone Number	:	503-812-1280
Fax Number	:

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

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	11/21/2012

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Directions to “ ALISHA SUE CLARK ” Practice Location

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