Provider Demographics
NPI:1972676617
Name:CLARK, KEVIN S (LMT, RAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT, RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:312 MAIN STREET
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-0215
Mailing Address - Country:US
Mailing Address - Phone:802-649-5252
Mailing Address - Fax:
Practice Address - Street 1:312 MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055-4418
Practice Address - Country:US
Practice Address - Phone:802-649-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2013-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1685R225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist