Provider Demographics
NPI:1477783769
Name:CLARK FAMILY CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:CLARK FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-843-1930
Mailing Address - Street 1:351 PASCOE BLVD.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-843-1930
Mailing Address - Fax:866-530-9599
Practice Address - Street 1:351 PASCOE BLVD.
Practice Address - Street 2:STE 106
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-843-1930
Practice Address - Fax:860-530-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003341Medicaid
KY000000477912OtherANTHEM
KY85003341Medicaid