Provider Demographics
NPI:1326190810
Name:CLUCK, DAVID S (ATC, PTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:S
Last Name:CLUCK
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4087
Mailing Address - Country:US
Mailing Address - Phone:610-935-0909
Mailing Address - Fax:
Practice Address - Street 1:915 OLD FERN HILL RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4269
Practice Address - Country:US
Practice Address - Phone:610-738-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE002849L225200000X
PART001455A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer