Provider Demographics
NPI:1972046308
Name:CLARK, MARCO (ATC)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-1614
Mailing Address - Country:US
Mailing Address - Phone:970-402-2746
Mailing Address - Fax:
Practice Address - Street 1:2032 9TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-1614
Practice Address - Country:US
Practice Address - Phone:970-402-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Z00000X
CO390200000X
COAT.00017082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program