Provider Demographics
NPI:1487950606
Name:CLARK, WILLIAM D (LMT)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:WILLIAM
Other - Middle Name:D
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:1160 LUCERNE LOOP RD NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9681
Mailing Address - Country:US
Mailing Address - Phone:863-287-6960
Mailing Address - Fax:
Practice Address - Street 1:1160 LUCERNE LOOP RD NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-9681
Practice Address - Country:US
Practice Address - Phone:863-287-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0019161225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist