Provider Demographics
NPI:1659578094
Name:RUZICKA, CLARK (DC)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:
Last Name:RUZICKA
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:PO BOX 1420
Mailing Address - Street 2:610 FRONT ST
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-1420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 FRONT ST
Practice Address - Street 2:BX1420
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-1420
Practice Address - Country:US
Practice Address - Phone:719-486-1175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2677111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic