Provider Demographics
NPI:1225052210
Name:CLARK, CHARLES JR (PT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7286
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:805 BLANKENBAKER PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1894
Practice Address - Country:US
Practice Address - Phone:502-253-0833
Practice Address - Fax:502-253-0834
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK099160OtherPTNA
KY186592Medicare ID - Type Unspecified