Provider Demographics
NPI:1013919638
Name:WILLIAMS, COREY CLARK (DC)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:CLARK
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 MAIN ST
Mailing Address - Street 2:PO BOX 255
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-4333
Mailing Address - Country:US
Mailing Address - Phone:701-683-4582
Mailing Address - Fax:701-683-5814
Practice Address - Street 1:906 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4333
Practice Address - Country:US
Practice Address - Phone:701-683-4582
Practice Address - Fax:701-683-5814
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18014Medicaid
MN21B47WIOtherBLUE SELECT MN
ND21439OtherBCBS ND
U48032Medicare UPIN
ND18014Medicaid