Provider Demographics
NPI:1326706045
Name:CLARK, GRANT CARSON (DC)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:CARSON
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 1:11536 CARSON HWY
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-8711
Mailing Address - Country:US
Mailing Address - Phone:217-440-3180
Mailing Address - Fax:
Practice Address - Street 1:136 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9811
Practice Address - Country:US
Practice Address - Phone:517-456-4033
Practice Address - Fax:517-456-8283
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401185111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor