Provider Demographics
NPI:1770971525
Name:CLARK, CALEB
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:CLARK
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 1:163 NEAL ST APT 2L
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 MIDDLE STREET
Practice Address - Street 2:504
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-699-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4787172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist