Provider Demographics
NPI:1467626481
Name:CLACK CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:CLACK CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-449-2116
Mailing Address - Street 1:3180 DREDGE DR STE C
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-0561
Mailing Address - Country:US
Mailing Address - Phone:406-449-2116
Mailing Address - Fax:406-513-1027
Practice Address - Street 1:3180 DREDGE DR STE C
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0561
Practice Address - Country:US
Practice Address - Phone:406-449-2116
Practice Address - Fax:406-513-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT921111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000084068Medicare PIN