Provider Demographics
NPI:1780624312
Name:CLARK WITTER, CHAMEIN K (DCPC)
Entity type:Individual
Prefix:DR
First Name:CHAMEIN
Middle Name:K
Last Name:CLARK WITTER
Suffix:
Gender:F
Credentials:DCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-344-4926
Mailing Address - Fax:563-344-8759
Practice Address - Street 1:3411 SPRING STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-344-4926
Practice Address - Fax:563-344-8759
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06365I111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0239160Medicaid
IAI1863Medicare ID - Type Unspecified