Provider Demographics
NPI:1134175474
Name:CLARK, CHRISTOPHER RUSSELL (DC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:RUSSELL
Last Name:CLARK
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 1:177 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-1818
Mailing Address - Country:US
Mailing Address - Phone:724-852-1777
Mailing Address - Fax:724-852-1777
Practice Address - Street 1:177 E HIGH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1818
Practice Address - Country:US
Practice Address - Phone:724-852-1777
Practice Address - Fax:724-852-1777
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007628L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01666127OtherGROUP HIGHMARK BCBS
PA1010082300001Medicaid
PA897504OtherINDIVIDUAL HIGHMARK BCBS
PA1134175474OtherINDIVIDUAL NPI NUMBER
PA1010082300001Medicaid
PA1134175474OtherINDIVIDUAL NPI NUMBER