Basic Information
| Provider Information | |||||||||
| NPI: | 1740719459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PAXTON | ||||||||
| MiddleName: | HENRY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2860 | ||||||||
| Address2: | |||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883112860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754349473 | ||||||||
| FaxNumber: | 5754372622 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 S CANYON ST | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882205733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756280503 | ||||||||
| FaxNumber: | 5754372622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 1707 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.