Provider Demographics
NPI:1265736508
Name:CLARK, KEVIN (DAOM, L AC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DAOM, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4905
Mailing Address - Country:US
Mailing Address - Phone:302-249-0143
Mailing Address - Fax:732-775-3515
Practice Address - Street 1:415 ROUTE 34
Practice Address - Street 2:SUITE 210
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-2522
Practice Address - Country:US
Practice Address - Phone:302-249-0143
Practice Address - Fax:732-775-3515
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-30
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECQ-0000029171100000X
NJ25MZ00104200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist