Provider Demographics
NPI:1568640530
Name:JEFFERY S. CLARK, D.C., P.A.
Entity Type:Organization
Organization Name:JEFFERY S. CLARK, D.C., P.A.
Other - Org Name:CLARK CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-780-0300
Mailing Address - Street 1:47 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3188
Mailing Address - Country:US
Mailing Address - Phone:207-780-0300
Mailing Address - Fax:866-265-5910
Practice Address - Street 1:47 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3188
Practice Address - Country:US
Practice Address - Phone:207-780-0300
Practice Address - Fax:866-265-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1101Medicare PIN