MEDICARE: TYLER CLARK DPT

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

General Provider Information

NPI Number	:	1427310069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER CLARK DPT

Provider Business Mailing Address
First Line	:	2100 SWIFT AVE
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116-3426
Country	:	US
Telephone Number	:	816-474-8877
Fax Number	:	816-474-8878

Provider Business Practice Location Address
First Line	:	2100 SWIFT AVE
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116-3426
Country	:	US
Telephone Number	:	816-474-8877
Fax Number	:	816-474-8878

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

Provider Enumeration Date	:	06/11/2012
Last Update Date	:	06/11/2012

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