Provider Demographics
NPI:1376639633
Name:LUNDGREN, CLARK D (DC)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:D
Last Name:LUNDGREN
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:PO BOX 2084
Mailing Address - Street 2:2401 MAIN ST E SUITE A
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873
Mailing Address - Country:US
Mailing Address - Phone:406-827-5500
Mailing Address - Fax:406-827-1986
Practice Address - Street 1:2401 MAIN ST E
Practice Address - Street 2:SUITE A
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873
Practice Address - Country:US
Practice Address - Phone:406-827-5500
Practice Address - Fax:406-827-1986
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT472111N00000X
MTMT472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0165360Medicaid
MT40933OtherBCBS
MT0165376Medicaid
MT1376639633OtherCHIROPRACTIC