Provider Demographics
NPI:1700017571
Name:CLARK, ROSS MYRACLE (DC)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:MYRACLE
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 1:1307 W REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5505
Mailing Address - Country:US
Mailing Address - Phone:731-885-0461
Mailing Address - Fax:
Practice Address - Street 1:1307 W REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5505
Practice Address - Country:US
Practice Address - Phone:731-885-0461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND.C. 2356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1093022600OtherGROUP NPI NUMBER
TN103I352408Medicare PIN