Provider Demographics
NPI:1215044201
Name:CONGER, CLINTON CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:CHARLES
Last Name:CONGER
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 1:2605 BREWERTON RD
Mailing Address - Street 2:
Mailing Address - City:MATTYDALE
Mailing Address - State:NY
Mailing Address - Zip Code:13211-1147
Mailing Address - Country:US
Mailing Address - Phone:315-415-2028
Mailing Address - Fax:
Practice Address - Street 1:2605 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:MATTYDALE
Practice Address - State:NY
Practice Address - Zip Code:13211-1147
Practice Address - Country:US
Practice Address - Phone:315-415-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0110111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor