Provider Demographics
NPI:1700527173
Name:CLARK, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 JAMES AVE APT A
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76706-2128
Mailing Address - Country:US
Mailing Address - Phone:214-929-7545
Mailing Address - Fax:
Practice Address - Street 1:1112 JAMES AVE APT A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-2128
Practice Address - Country:US
Practice Address - Phone:214-929-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer