Provider Demographics
NPI:1538593009
Name:CLARK, KIMBERLY CAROL (BS CMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CAROL
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8874 PINE ISLAND CT S
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9570
Mailing Address - Country:US
Mailing Address - Phone:269-720-6833
Mailing Address - Fax:
Practice Address - Street 1:7901 S 12TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3831
Practice Address - Country:US
Practice Address - Phone:269-720-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI225700000XOtherMASSAGE THERAPIST