Provider Demographics
NPI:1669595054
Name:HELLER, CLARK D (DC)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:D
Last Name:HELLER
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 1:1221 PHOENIX ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2340
Mailing Address - Country:US
Mailing Address - Phone:262-728-8208
Mailing Address - Fax:262-728-9818
Practice Address - Street 1:1221 PHOENIX ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2340
Practice Address - Country:US
Practice Address - Phone:262-728-8208
Practice Address - Fax:262-728-9818
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4069-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000535686OtherPTAN