Provider Demographics
NPI:1255406971
Name:CLARK FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:CLARK FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-484-0805
Mailing Address - Street 1:2300 SOUTH 57TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-484-0805
Mailing Address - Fax:479-452-1475
Practice Address - Street 1:2300 SOUTH 57TH STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-484-0805
Practice Address - Fax:479-452-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1597111N00000X
AR1596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5X058OtherBCBS
5X057OtherBCBS
AR5C675Medicare ID - Type Unspecified
U91037Medicare UPIN
5X058OtherBCBS