Dallas Layne Clark, P.T.

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

802 Issued in WY

Practice address

20 Adaville Drive
Suite 10
Diamondville, WY 83116

Phone

(307) 877-1000

Fax

(307) 877-1000

NPI assigned

Oct 13, 2006

Last updated

Jul 9, 2007By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in WY

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 1987

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Pro Physical Therapy LLC

  • Physical Therapist
  • Diamondville, WY
  • NPI 1164619078
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160697600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1972693497",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 152",
            "city": "LAKETOWN",
            "state": "UT",
            "postal_code": "840380152",
            "telephone_number": "435-946-3512",
            "fax_number": "435-946-2311"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 ADAVILLE DRIVE",
            "address_2": "SUITE 10",
            "city": "DIAMONDVILLE",
            "state": "WY",
            "postal_code": "83116",
            "telephone_number": "307-877-1000",
            "fax_number": "307-877-1000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "DALLAS",
        "middle_name": "LAYNE",
        "name_prefix": "Mr.",
        "credential": "P.T.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-13",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "UT",
            "license": "6293691-2401",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "WY",
            "license": "802",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "313318",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST HEALTH PROVIDER NUM",
            "identifier": "2282218",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH PROVIDER ID",
            "identifier": "11433480",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CCN PROVIDER NUMBER",
            "identifier": "5586872",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kathy Bella, ARNP FNP-C
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• Micah Daniel Himmerich, DDS
• Kemmerer Dental Inc (Kemmerer Dental Associates)
• Pro Physical Therapy LLC

• Physical Therapist in Diamondville, WY
• Providers in Diamondville, WY by specialty
• Physical Therapist in Wyoming

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.