Provider Demographics
NPI:1790115004
Name:CLARK, KEVIN JOHN (LCPO)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 12TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5599
Mailing Address - Country:US
Mailing Address - Phone:206-328-4276
Mailing Address - Fax:206-328-1037
Practice Address - Street 1:411 12TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5599
Practice Address - Country:US
Practice Address - Phone:206-328-4276
Practice Address - Fax:206-328-1037
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA01 60414623222Z00000X
WAPS 60414610224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9015561Medicaid