Individual
MADISON RAE CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
15413 E 3RD TER S, INDEPENDENCE, MO 64050-2289
(816) 585-5717
Mailing address
411 CENTRAL METHODIST SQ, FAYETTE, MO 65248-1104
(816) 585-5717
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
11/29/2016
Last updated
12/01/2016
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