Provider Demographics
NPI:1326254798
Name:CLARK CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC CENTER, LLC
Other - Org Name:CHRISTOPHER R. CLARK, D.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:I
Authorized Official - Credentials:DC
Authorized Official - Phone:724-852-1777
Mailing Address - Street 1:177 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-1818
Mailing Address - Country:US
Mailing Address - Phone:724-852-1777
Mailing Address - Fax:724-852-1777
Practice Address - Street 1:177 E HIGH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1818
Practice Address - Country:US
Practice Address - Phone:724-852-1777
Practice Address - Fax:724-852-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007628L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1666127OtherOGANIZATION BCBS NUMBER
PA$$$$$$$$$OtherSOCIAL SECURITY NUMBER
PA1010082300001Medicaid
PA1134175474OtherINDIVIDUAL NPI NUMBER
PA1326254798OtherNPI NUMBER - GROUP
PA041052XGYOtherMEDICARE MEMBER PROVIDER
PA897504OtherINDIVIDUAL BCBS NUMBER
PA1326254798OtherNPI NUMBER - GROUP