Provider Demographics
NPI:1700274628
Name:CLARK, DREW (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:DREW
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 S ROBERTSON BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1613
Mailing Address - Country:US
Mailing Address - Phone:310-360-0882
Mailing Address - Fax:
Practice Address - Street 1:822 S ROBERTSON BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1613
Practice Address - Country:US
Practice Address - Phone:310-360-0882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist