Provider Demographics
NPI:1710025200
Name:CLARK CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:443-637-4936
Mailing Address - Street 1:4639 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-5455
Mailing Address - Country:US
Mailing Address - Phone:443-637-4936
Mailing Address - Fax:443-637-4946
Practice Address - Street 1:4639 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-5455
Practice Address - Country:US
Practice Address - Phone:443-637-4936
Practice Address - Fax:443-637-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1464PT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU24311Medicare UPIN
MDG02232Medicare PIN