Provider Demographics
NPI:1972756708
Name:CLARK 04/21/1970, DANIEL AVERY
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:AVERY
Last Name:CLARK 04/21/1970
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003
Mailing Address - Country:US
Mailing Address - Phone:801-756-3860
Mailing Address - Fax:801-756-3870
Practice Address - Street 1:160 N CENTER ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1647
Practice Address - Country:US
Practice Address - Phone:801-756-3860
Practice Address - Fax:801-756-3860
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368980-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist