Provider Demographics
NPI:1093849606
Name:CLARK, MATTHEW ERICK (ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ERICK
Last Name:CLARK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 COOPER LN
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19363-4012
Mailing Address - Country:US
Mailing Address - Phone:610-932-8547
Mailing Address - Fax:610-359-1686
Practice Address - Street 1:2004 SPROUL RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3511
Practice Address - Country:US
Practice Address - Phone:610-353-0800
Practice Address - Fax:610-359-1686
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002008A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer