Provider Demographics
NPI:1588799563
Name:CLARK CHIROPRACTIC, L.L.C.
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:337-232-3353
Mailing Address - Street 1:854 KALISTE SALOOM RD STE C
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4367
Mailing Address - Country:US
Mailing Address - Phone:337-232-3353
Mailing Address - Fax:337-232-9304
Practice Address - Street 1:854 KALISTE SALOOM RD STE C
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4367
Practice Address - Country:US
Practice Address - Phone:337-232-3353
Practice Address - Fax:337-232-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU97711Medicare UPIN
LA4C889CT32Medicare PIN