Provider Demographics
NPI:1093345811
Name:CLARK PHYSICAL THERAPY & BODYWORK, PLC
Entity Type:Organization
Organization Name:CLARK PHYSICAL THERAPY & BODYWORK, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-349-1808
Mailing Address - Street 1:621 SPLIT ROCK RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-2106
Mailing Address - Country:US
Mailing Address - Phone:802-877-9929
Mailing Address - Fax:802-453-2988
Practice Address - Street 1:614 MONKTON RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443-5392
Practice Address - Country:US
Practice Address - Phone:802-349-1808
Practice Address - Fax:802-453-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6702477Medicaid