Provider Demographics
NPI:1003119272
Name:CLARK, CHARLES JR (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16222 N 59TH AVE
Mailing Address - Street 2:SUITE A100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1705
Mailing Address - Country:US
Mailing Address - Phone:623-334-4000
Mailing Address - Fax:623-334-4400
Practice Address - Street 1:16222 N 59TH AVE
Practice Address - Street 2:SUITE A100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1705
Practice Address - Country:US
Practice Address - Phone:623-334-4000
Practice Address - Fax:623-334-4400
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ7094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor