Provider Demographics
NPI:1487865044
Name:CLARK, WILLIAM KYLE (LMT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KYLE
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
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 641268
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0304
Mailing Address - Country:US
Mailing Address - Phone:270-745-1467
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:313 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-1424
Practice Address - Country:US
Practice Address - Phone:270-952-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262418225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY91011148Medicaid
KY91011148Medicaid