Provider Demographics
NPI:1073046421
Name:CLARK, BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HIDDEN LAKE LANE
Mailing Address - Street 2:
Mailing Address - City:PENINSULA
Mailing Address - State:OH
Mailing Address - Zip Code:44264
Mailing Address - Country:US
Mailing Address - Phone:330-703-6998
Mailing Address - Fax:
Practice Address - Street 1:3869 DARROW RD
Practice Address - Street 2:STE 206
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224
Practice Address - Country:US
Practice Address - Phone:440-534-9209
Practice Address - Fax:440-557-6371
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor