Provider Demographics
NPI:1639575830
Name:CLARK, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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 1:7 REEF RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:GU
Mailing Address - Zip Code:83901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 REEF RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:GU
Practice Address - Zip Code:83901
Practice Address - Country:US
Practice Address - Phone:202-613-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-15
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer