Individual
MR. KENNETH DALE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
Primary
400
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00J21A
GROUP MEDICARE NUMBER
TX
01
—
094010801
GROUP MEDICAID NUMBER
TX
Enumeration date
09/06/2011
Last updated
09/27/2011
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