Individual
JUSTIN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
12923 NW CORNELL RD, #201, PORTLAND, OR 97229-5834
(503) 646-3393
Mailing address
12923 NW CORNELL RD, #201, PORTLAND, OR 97229-5834
(503) 646-3393
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
18505
OR
Other
Enumeration date
12/23/2011
Last updated
12/23/2011
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