Provider Demographics
NPI:1306172721
Name:CLARK, NICHOLAS EUGENE (LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:EUGENE
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 VALLEY RANCH PKWY E
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5405
Mailing Address - Country:US
Mailing Address - Phone:972-968-5061
Mailing Address - Fax:972-968-5145
Practice Address - Street 1:8401 VALLEY RANCH PKWY E
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-5405
Practice Address - Country:US
Practice Address - Phone:972-968-5061
Practice Address - Fax:972-968-5145
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT32882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer