Provider Demographics
NPI:1629177340
Name:DANA E. CLARK D.C. INC
Entity Type:Organization
Organization Name:DANA E. CLARK D.C. INC
Other - Org Name:PACIFIC COAST SPINE AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:ELMORE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-473-7130
Mailing Address - Street 1:11110 OHIO AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6345
Mailing Address - Country:US
Mailing Address - Phone:310-473-7130
Mailing Address - Fax:310-473-5077
Practice Address - Street 1:11110 OHIO AVE STE 108
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6345
Practice Address - Country:US
Practice Address - Phone:310-473-7130
Practice Address - Fax:310-473-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU93711Medicare UPIN
CAW20278Medicare PIN