Provider Demographics
NPI:1376730689
Name:CLARK, BETH ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3339
Mailing Address - Country:US
Mailing Address - Phone:716-675-4134
Mailing Address - Fax:716-675-5733
Practice Address - Street 1:1953 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3339
Practice Address - Country:US
Practice Address - Phone:716-675-4134
Practice Address - Fax:716-675-5733
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor