Active NPI
Charles Kevin Clark, P.T.
- Physical Therapist
- Phoenix, AZ
National Provider Identifier
1093722902
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 5471
- Practice address
- 10214 N Tatum Blvd
Suite B-500
Phoenix, AZ 85028-4224 - Phone
- (480) 264-6326
- Fax
- (480) 264-6328
- NPI assigned
- Aug 2, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 5471 | AZ | Primary |
Addresses
Primary practice location
10214 N Tatum Blvd
Suite B-500
Phoenix, AZ 85028-4224
Mailing address
10214 N Tatum Blvd
Ste B500
Phoenix, AZ 85028-4224
Phone (480) 236-5360
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5471 | AZ | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154476800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1567987200000",
"number": "1093722902",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10214 N TATUM BLVD",
"address_2": "STE B500",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850284224",
"telephone_number": "480-236-5360",
"fax_number": "480-991-0139"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10214 N TATUM BLVD",
"address_2": "SUITE B-500",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850284224",
"telephone_number": "480-264-6326",
"fax_number": "480-264-6328"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "CHARLES",
"middle_name": "KEVIN",
"name_prefix": "Mr.",
"credential": "P.T.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-02",
"last_updated": "2019-09-09",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "AZ",
"license": "5471",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Phoenix, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.