Individual
MR. DALLAS LAYNE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
20 ADAVILLE DRIVE, SUITE 10, DIAMONDVILLE, WY 83116
(307) 877-1000
(307) 877-1000
Mailing address
PO BOX 152, LAKETOWN, UT 84038-0152
(435) 946-3512
(435) 946-2311
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
6293691-2401
UT
225100000X
Physical Therapist
Primary
802
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11433480
CAQH PROVIDER ID
WY
01
—
2282218
FIRST HEALTH PROVIDER NUM
WY
01
—
313318
BLUE CROSS BLUE SHIELD
WY
01
—
5586872
CCN PROVIDER NUMBER
WY
Enumeration date
10/13/2006
Last updated
07/09/2007
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