Provider Demographics
NPI:1922207125
Name:CLARK, CHRISTINA RAE (LAC MSOM, DIPLOM)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC MSOM, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19926 PORCUPINE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2090
Mailing Address - Country:US
Mailing Address - Phone:541-961-7947
Mailing Address - Fax:
Practice Address - Street 1:911 NE 4TH ST STE 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4647
Practice Address - Country:US
Practice Address - Phone:541-961-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT99088171100000X
OR205587171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT99088OtherMONTANA STATE ACUPUNCTURE LICENSE
OR205587OtherOREGON STATE ACUPUNCTURE LICENSE
MT221OtherSTATE LICENSE