MEDICARE: MR. BRIAN CLARK ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1538618277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN CLARK ATC

Provider Business Mailing Address
First Line	:	9950 BRUCEVILLE RD APT 147
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-9511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9950 BRUCEVILLE RD APT 147
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-9511
Country	:	US
Telephone Number	:	916-513-0964
Fax Number	:

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

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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