Provider Demographics
NPI:1851413298
Name:CLARK CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-479-2400
Mailing Address - Street 1:69 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1228
Mailing Address - Country:US
Mailing Address - Phone:617-479-2400
Mailing Address - Fax:
Practice Address - Street 1:69 WILLARD ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1228
Practice Address - Country:US
Practice Address - Phone:617-479-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY40011OtherBCBS GROUP
MA648938OtherTUFTS GROUP #
MA0039113OtherNHP GROUP #