Provider Demographics
NPI:1013238393
Name:CLARK CHIROPRACTIC CENTER INC
Entity type:Organization
Organization Name:CLARK CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-567-0771
Mailing Address - Street 1:822 BARKER ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4808
Mailing Address - Country:US
Mailing Address - Phone:772-567-0771
Mailing Address - Fax:772-567-0575
Practice Address - Street 1:2706 20TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3001
Practice Address - Country:US
Practice Address - Phone:772-567-0771
Practice Address - Fax:772-567-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty