Provider Demographics
NPI:1316682297
Name:CLARK, JOHN HARRISON (DPT)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HARRISON
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
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Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:7600 N MINERAL DR STE 500
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9425
Practice Address - Country:US
Practice Address - Phone:208-457-4208
Practice Address - Fax:208-457-4197
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1316682297Medicaid