Provider Demographics
NPI:1215493358
Name:VANDEGRAFT, CLARK O (PTA)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:O
Last Name:VANDEGRAFT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61554
Mailing Address - Country:US
Mailing Address - Phone:309-840-1720
Mailing Address - Fax:
Practice Address - Street 1:3614 N ROCHELLE LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1039
Practice Address - Country:US
Practice Address - Phone:309-688-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant