Provider Demographics
NPI:1598046401
Name:CLARK, KENNETH DALE
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DALE
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9303 PINECROFT DR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3181
Mailing Address - Country:US
Mailing Address - Phone:281-297-6445
Mailing Address - Fax:281-297-6460
Practice Address - Street 1:9303 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3181
Practice Address - Country:US
Practice Address - Phone:281-297-6445
Practice Address - Fax:281-297-6460
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX400222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094010801OtherGROUP MEDICAID NUMBER
TX00J21AOtherGROUP MEDICARE NUMBER