Provider Demographics
NPI:1497201370
Name:MATTHEW CLARK
Entity Type:Organization
Organization Name:MATTHEW CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-747-7776
Mailing Address - Street 1:5250 S COMMERCE DR
Mailing Address - Street 2:SUITE 155
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5250 S COMMERCE DR
Practice Address - Street 2:SUITE 155
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7926
Practice Address - Country:US
Practice Address - Phone:801-747-7776
Practice Address - Fax:385-800-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9647019-1202111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty