Provider Demographics
NPI:1629281001
Name:CLARK FAMILY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:CLARK FAMILY CHIROPRACTIC INC
Other - Org Name:CLARK CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-845-0001
Mailing Address - Street 1:500 SAN JUAN ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2517
Mailing Address - Country:US
Mailing Address - Phone:719-845-0001
Mailing Address - Fax:
Practice Address - Street 1:500 SAN JUAN ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2517
Practice Address - Country:US
Practice Address - Phone:719-845-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC507268Medicare ID - Type Unspecified