Provider Demographics
NPI:1699847780
Name:GARY W. CLARK A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GARY W. CLARK A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:888-437-3668
Mailing Address - Street 1:166 W 1325 N STE 300
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-7854
Mailing Address - Country:US
Mailing Address - Phone:435-867-8521
Mailing Address - Fax:
Practice Address - Street 1:444 S. MAIN
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:UT
Practice Address - Zip Code:84751
Practice Address - Country:US
Practice Address - Phone:888-437-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3207290501332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment