Provider Demographics
NPI:1619075298
Name:CLARK, RAYMOND GEORGE (DC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:GEORGE
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 1:1306 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3707
Mailing Address - Country:US
Mailing Address - Phone:701-235-1360
Mailing Address - Fax:701-235-1360
Practice Address - Street 1:1306 23RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3707
Practice Address - Country:US
Practice Address - Phone:701-235-1360
Practice Address - Fax:701-235-1360
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4313Medicare ID - Type Unspecified