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NPI Code Detail

MEDICARE: AUSTIN F CLARK DPT

MEDICARE: AUSTIN F 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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1588109078
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUSTIN F CLARK DPT
Provider Business Mailing Address
First Line : 625 ENTERPRISE DR
Second Line :
City : OAK BROOK
State : IL
Zip : 60523-8813
Country : US
Telephone Number : 630-575-6200
Fax Number :
Provider Business Practice Location Address
First Line : 951 WATERBURY FALLS DR
Second Line :
City : O FALLON
State : MO
Zip : 63368-2202
Country : US
Telephone Number : 636-336-0300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/20/2016
Last Update Date : 12/20/2016

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