Provider Demographics
NPI:1679857544
Name:CLARK, KENT EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:EDWARD
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 1:15B LOUDOUN ST SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-2908
Mailing Address - Country:US
Mailing Address - Phone:703-779-7909
Mailing Address - Fax:
Practice Address - Street 1:15B LOUDOUN ST SW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-2908
Practice Address - Country:US
Practice Address - Phone:703-779-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8302111NN1001X
VA0104-557256111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition