Provider Demographics
NPI:1376215483
Name:ELLENSBURG SPORT AND SPINE, LLC
Entity Type:Organization
Organization Name:ELLENSBURG SPORT AND SPINE, LLC
Other - Org Name:CLARK CHIROPRACTIC AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DILLON
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-791-6226
Mailing Address - Street 1:314 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3366
Mailing Address - Country:US
Mailing Address - Phone:360-791-6226
Mailing Address - Fax:
Practice Address - Street 1:314 N PINE ST
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3366
Practice Address - Country:US
Practice Address - Phone:360-791-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH60875207OtherSTATE OF WASHINGTON