Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 291868 | CA |
NPI | 1043764525 |
---|---|
Provider Name | Andrew Clark |
First Address | Manhattan Beach, CA 90266-7015 |
Second Address | Manhattan Beach, CA 90266-7015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2016 |
Last Update Date | 12/08/2016 |