Basic Information
| Provider Information | |||||||||
| NPI: | 1003297706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6070 S 1ST ST STE D | ||||||||
| Address2: | P.O. BOX 1004 | ||||||||
| City: | MILAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383583186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316132214 | ||||||||
| FaxNumber: | 7316132215 | ||||||||
| Practice Location | |||||||||
| Address1: | 6070 S 1ST ST STE D | ||||||||
| Address2: | |||||||||
| City: | MILAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383583186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316132214 | ||||||||
| FaxNumber: | 7316132215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10386 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.