Provider Demographics
NPI:1184964876
Name:CLARK CHIROPRACTIC CENTRE
Entity type:Organization
Organization Name:CLARK CHIROPRACTIC CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-471-0440
Mailing Address - Street 1:28800 W 8 MILE RD
Mailing Address - Street 2:STE 5858
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5906
Mailing Address - Country:US
Mailing Address - Phone:248-471-0440
Mailing Address - Fax:248-471-6270
Practice Address - Street 1:28800 W 8 MILE RD
Practice Address - Street 2:STE 5858
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5906
Practice Address - Country:US
Practice Address - Phone:248-471-0440
Practice Address - Fax:248-471-6270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-18
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F33353OtherBCBS
MI0F33353OtherBCBS