Provider Demographics
NPI:1952686818
Name:I CLARK LABRUM DC PC
Entity Type:Organization
Organization Name:I CLARK LABRUM DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:I
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:LABRUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:4335-673-2700
Mailing Address - Street 1:415 W TABERNACLE ST
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3797
Mailing Address - Country:US
Mailing Address - Phone:435-673-2700
Mailing Address - Fax:434-673-2714
Practice Address - Street 1:415 W TABERNACLE ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3797
Practice Address - Country:US
Practice Address - Phone:435-673-2700
Practice Address - Fax:434-673-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT166111-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0000005724Medicare PIN