Provider Demographics
NPI:1811290935
Name:CLARK, CHARLES WARREN JR (LMT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WARREN
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19577 FM 2854 RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-3150
Mailing Address - Country:US
Mailing Address - Phone:936-537-0948
Mailing Address - Fax:
Practice Address - Street 1:19577 FM 2854 RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-3150
Practice Address - Country:US
Practice Address - Phone:936-537-0948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-11
Last Update Date:2010-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT038025225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist