Provider Demographics
NPI:1659783363
Name:CLARK CHIROPRACTIC AND MASSAGE PS
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC AND MASSAGE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-452-7636
Mailing Address - Street 1:601 S RACE ST STE C
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6400
Mailing Address - Country:US
Mailing Address - Phone:360-452-7636
Mailing Address - Fax:
Practice Address - Street 1:601 S RACE ST STE C
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6400
Practice Address - Country:US
Practice Address - Phone:360-452-7636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.60465702261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center