Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports |
NPI | 1376170613 |
---|---|
Provider Name | Kyle Clark |
First Address | Alpharetta, GA 30005-5481 |
Second Address | Alpharetta, GA 30005-5481 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2020 |
Last Update Date | 26/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
140547 | CHILDREN'S HEALTHCARE OF ATLANTA (01) |