Provider Demographics
NPI:1164461703
Name:CLARK, CARRIE ELLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9744 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4249
Mailing Address - Country:US
Mailing Address - Phone:612-382-7408
Mailing Address - Fax:952-927-4226
Practice Address - Street 1:3948 W 50TH ST
Practice Address - Street 2:STE 203
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1210
Practice Address - Country:US
Practice Address - Phone:952-920-4528
Practice Address - Fax:952-927-4226
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU81975Medicare UPIN