Provider Demographics
NPI:1598359762
Name:ANDERSON, CLARK (RRT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8051 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-7216
Mailing Address - Country:US
Mailing Address - Phone:970-409-2474
Mailing Address - Fax:
Practice Address - Street 1:8051 DECATUR ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-7216
Practice Address - Country:US
Practice Address - Phone:970-409-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31698277-0000332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies