Provider Demographics
NPI:1619009438
Name:CLARK CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-852-9355
Mailing Address - Street 1:507 E PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3126
Mailing Address - Country:US
Mailing Address - Phone:270-852-9355
Mailing Address - Fax:270-852-1870
Practice Address - Street 1:507 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3126
Practice Address - Country:US
Practice Address - Phone:270-852-9355
Practice Address - Fax:270-852-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003150Medicaid
KY85003150Medicaid