Provider Demographics
NPI:1700904778
Name:CLARK CHIROPRACTIC INC
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-255-0427
Mailing Address - Street 1:17422 108TH AVE SE #101
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5400
Mailing Address - Country:US
Mailing Address - Phone:425-255-0427
Mailing Address - Fax:425-255-1066
Practice Address - Street 1:17422 108TH AVE SE
Practice Address - Street 2:101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5400
Practice Address - Country:US
Practice Address - Phone:425-255-0427
Practice Address - Fax:425-255-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02269Medicare UPIN
000109303Medicare ID - Type Unspecified