Provider Demographics
NPI:1548647423
Name:CLARK, COULTER LOUIS (MED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:COULTER
Middle Name:LOUIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N BROADWAY ST STE C
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-1222
Mailing Address - Country:US
Mailing Address - Phone:580-548-3283
Mailing Address - Fax:
Practice Address - Street 1:355 S OSAGE ST
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-2015
Practice Address - Country:US
Practice Address - Phone:918-396-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer