Individual
MR. KENNETH DALE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
9303 PINECROFT DR, THE WOODLANDS, TX 77380-3181
(281) 297-6445
(281) 297-6460
Mailing address
9303 PINECROFT DR, THE WOODLANDS, TX 77380-3181
(281) 297-6445
(281) 297-6460
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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