Provider Demographics
NPI:1831536994
Name:CLARK, CHAD ALAN
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ALAN
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 1:560 MEMORIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4073
Mailing Address - Country:US
Mailing Address - Phone:208-232-4267
Mailing Address - Fax:855-319-1499
Practice Address - Street 1:560 MEMORIAL DR STE C
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4073
Practice Address - Country:US
Practice Address - Phone:208-232-4267
Practice Address - Fax:855-319-1499
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT - 3181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid
IDPENDINGMedicaid