Provider Demographics
NPI:1275650657
Name:CLARK, SCOTT C (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
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 1:1540 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3906
Mailing Address - Country:US
Mailing Address - Phone:847-359-9864
Mailing Address - Fax:847-259-9866
Practice Address - Street 1:1540 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3906
Practice Address - Country:US
Practice Address - Phone:847-259-9864
Practice Address - Fax:847-259-9866
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU67478Medicare UPIN
IL313420Medicare UPIN