Provider Demographics
NPI:1497830186
Name:CLARK, CRAIG RAYMOND (DC)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:RAYMOND
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 RED HILL AVE
Mailing Address - Street 2:#120
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3400
Mailing Address - Country:US
Mailing Address - Phone:714-708-2828
Mailing Address - Fax:714-708-2971
Practice Address - Street 1:3140 RED HILL AVE
Practice Address - Street 2:#120
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3400
Practice Address - Country:US
Practice Address - Phone:714-708-2828
Practice Address - Fax:714-708-2971
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T17666Medicare UPIN
DC013980Medicare ID - Type Unspecified