Provider Demographics
NPI:1891740478
Name:CLARK, GRENVILLE (MPT)
Entity Type:Individual
Prefix:MR
First Name:GRENVILLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2493
Mailing Address - Country:US
Mailing Address - Phone:828-785-4700
Mailing Address - Fax:828-552-5566
Practice Address - Street 1:5301 PROVIDENCE RD
Practice Address - Street 2:SUITE 80
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4128
Practice Address - Country:US
Practice Address - Phone:757-467-1900
Practice Address - Fax:757-467-7900
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP11167225100000X
VA2305202681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist