Provider Demographics
NPI:1295402659
Name:CLARK, NICHOLAS (DPT)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 46
Mailing Address - Street 2:
Mailing Address - City:KNIGHTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47857-0046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:954 E KNIGHT ST
Practice Address - Street 2:
Practice Address - City:KNIGHTSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47857-8023
Practice Address - Country:US
Practice Address - Phone:812-223-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist