Provider Demographics
NPI:1750304481
Name:CLARK, JOSEPH C (DC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-0248
Mailing Address - Country:US
Mailing Address - Phone:918-256-5111
Mailing Address - Fax:918-256-5222
Practice Address - Street 1:803 N FOREMAN ST
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-1435
Practice Address - Country:US
Practice Address - Phone:918-256-5111
Practice Address - Fax:918-256-5222
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007743111N00000X
OK4016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA2679OtherMEDICARE PTAN
GA35ZCJHQMedicare ID - Type Unspecified
GAGRP1678Medicare ID - Type UnspecifiedGROUP NUMBER
OKOKAAA2679OtherMEDICARE PTAN