Provider Demographics
NPI:1073548996
Name:CLARK, TRACI D (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
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:PO BOX 7353
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804
Mailing Address - Country:US
Mailing Address - Phone:252-446-7246
Mailing Address - Fax:252-446-5407
Practice Address - Street 1:224 N FAIRVIEW ROAD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801
Practice Address - Country:US
Practice Address - Phone:252-446-7246
Practice Address - Fax:252-446-5407
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085PHMedicaid
NC89085PHMedicaid
NC2456896AMedicare PIN