Provider Demographics
NPI:1841567252
Name:MASHELL CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:MASHELL CHIROPRACTIC CLINIC, INC.
Other - Org Name:DALE E. CLARK, D.C., P.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-832-6200
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:109 RAINIER AVE SO, STE C
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-0546
Mailing Address - Country:US
Mailing Address - Phone:360-832-6200
Mailing Address - Fax:360-832-6201
Practice Address - Street 1:109 RAINIER AVE SO
Practice Address - Street 2:SUITE C
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328-0546
Practice Address - Country:US
Practice Address - Phone:360-832-6200
Practice Address - Fax:360-832-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH0001250261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG001001561Medicare UPIN