Provider Demographics
NPI:1972693497
Name:CLARK, DALLAS LAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:DALLAS
Middle Name:LAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
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 152
Mailing Address - Street 2:
Mailing Address - City:LAKETOWN
Mailing Address - State:UT
Mailing Address - Zip Code:84038-0152
Mailing Address - Country:US
Mailing Address - Phone:435-946-3512
Mailing Address - Fax:435-946-2311
Practice Address - Street 1:20 ADAVILLE DRIVE
Practice Address - Street 2:SUITE 10
Practice Address - City:DIAMONDVILLE
Practice Address - State:WY
Practice Address - Zip Code:83116
Practice Address - Country:US
Practice Address - Phone:307-877-1000
Practice Address - Fax:307-877-1000
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6293691-2401225100000X
WY802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY2282218OtherFIRST HEALTH PROVIDER NUM
WY5586872OtherCCN PROVIDER NUMBER
WY313318OtherBLUE CROSS BLUE SHIELD
WY11433480OtherCAQH PROVIDER ID
WY5586872OtherCCN PROVIDER NUMBER