Provider Demographics
NPI:1083195390
Name:CLARK, JAMES (DPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 LAKE MICHIGAN DR NW STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-6300
Mailing Address - Country:US
Mailing Address - Phone:616-608-9978
Mailing Address - Fax:
Practice Address - Street 1:7169 KALAMAZOO AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8146
Practice Address - Country:US
Practice Address - Phone:616-827-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501018851OtherLICENSE