Basic Information
| Provider Information | |||||||||
| NPI: | 1427672740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BILBREY | ||||||||
| FirstName: | CLARK | ||||||||
| MiddleName: | TANNER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 W 300 S | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463859629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152902737 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3691 WILLOWCREEK RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463685080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2020 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 36003318A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 05013728A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05013728A | 01 | IN | INDIANA PROFESSIONAL LICENSING AGENCY | OTHER | 36003318A | 01 | IN | INDIANA PROFESSIONAL LICENSING AGENCY | OTHER |