Basic Information
| Provider Information | |||||||||
| NPI: | 1891041018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | JEFF | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1844 | ||||||||
| Address2: | |||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296331844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644820064 | ||||||||
| FaxNumber: | 8644820081 | ||||||||
| Practice Location | |||||||||
| Address1: | 12023 N RADIO STATION RD | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296781143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649850770 | ||||||||
| FaxNumber: | 8649851770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2012 | ||||||||
| LastUpdateDate: | 07/25/2012 | ||||||||
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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 | 6774 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.