Provider Demographics
NPI:1467516856
Name:CLARK CHIROPRACTIC HEALTH CENTER INC
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-528-2808
Mailing Address - Street 1:2909 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-2103
Mailing Address - Country:US
Mailing Address - Phone:727-528-2808
Mailing Address - Fax:727-824-8855
Practice Address - Street 1:2909 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-2103
Practice Address - Country:US
Practice Address - Phone:727-528-2808
Practice Address - Fax:727-824-8855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003633111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7107AMedicare PIN
FLP00240601Medicare ID - Type UnspecifiedRAILROAD MEDICARE ONLY