Provider Demographics
NPI:1023581808
Name:CLARK D LUNDGREN DC LLC
Entity type:Organization
Organization Name:CLARK D LUNDGREN DC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUNDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-827-5500
Mailing Address - Street 1:PO BOX 2084
Mailing Address - Street 2:
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873-2084
Mailing Address - Country:US
Mailing Address - Phone:406-827-5500
Mailing Address - Fax:406-827-1986
Practice Address - Street 1:2401 MAIN STREET EAST, SUITE A
Practice Address - Street 2:
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873-2401
Practice Address - Country:US
Practice Address - Phone:406-827-5500
Practice Address - Fax:406-827-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT41726OtherBLUE CROSS AND BLUE SHIELD OF MONTANA