Provider Demographics
NPI:1164498481
Name:CLARK, CHANIN PAIGE (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHANIN
Middle Name:PAIGE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9735 NW 5TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6816
Mailing Address - Country:US
Mailing Address - Phone:954-346-6076
Mailing Address - Fax:
Practice Address - Street 1:8181 N PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1543
Practice Address - Country:US
Practice Address - Phone:954-724-0595
Practice Address - Fax:954-724-0696
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY031QMedicare ID - Type UnspecifiedPROVIDER NUMBER