Provider Demographics
NPI:1245581214
Name:CLARK, KIOFA ENEZ (DC)
Entity Type:Individual
Prefix:DR
First Name:KIOFA
Middle Name:ENEZ
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 1:3048 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-3841
Mailing Address - Country:US
Mailing Address - Phone:478-746-3116
Mailing Address - Fax:478-746-2136
Practice Address - Street 1:3048 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3841
Practice Address - Country:US
Practice Address - Phone:478-746-3116
Practice Address - Fax:478-746-2136
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor