Basic Information
| Provider Information | |||||||||
| NPI: | 1891395422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | BURK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 S. 700 E | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841022142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019354171 | ||||||||
| FaxNumber: | 8019354946 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S. 700 E | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841022142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019354171 | ||||||||
| FaxNumber: | 8019354946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2020 | ||||||||
| LastUpdateDate: | 11/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.