Provider Demographics
NPI:1265530232
Name:CLARK, MICHAEL L (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
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 1:3031 S RUSSELL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-721-8825
Mailing Address - Fax:406-327-6702
Practice Address - Street 1:3031 S RUSSELL
Practice Address - Street 2:SUITE 4
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-721-8825
Practice Address - Fax:406-327-6702
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT160706Medicaid
MT40161OtherBC/BS
MT160706Medicaid
MT633157Medicare PIN