Provider Demographics
NPI:1093722902
Name:CLARK, CHARLES KEVIN (PT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:KEVIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10214 N TATUM BLVD
Mailing Address - Street 2:STE B500
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4224
Mailing Address - Country:US
Mailing Address - Phone:480-236-5360
Mailing Address - Fax:480-991-0139
Practice Address - Street 1:10214 N TATUM BLVD
Practice Address - Street 2:SUITE B-500
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4224
Practice Address - Country:US
Practice Address - Phone:480-264-6326
Practice Address - Fax:480-264-6328
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist