Provider Demographics
NPI:1285845362
Name:CLARK, JAMES DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2318
Mailing Address - Country:US
Mailing Address - Phone:843-374-7378
Mailing Address - Fax:843-374-7379
Practice Address - Street 1:414 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2318
Practice Address - Country:US
Practice Address - Phone:843-374-7378
Practice Address - Fax:843-374-7379
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1126225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1126OtherLICENSE NUMBER