Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10386 | TN |
NPI | 1003297706 |
---|---|
Provider Name | Adam Clark |
First Address | Milan, TN 38358-3186 |
Second Address | Milan, TN 38358-3186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2015 |
Last Update Date | 18/06/2015 |