Provider Demographics
NPI:1780751453
Name:CLARK, ERIC M (DC)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:CLARK
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 1:500 SAN JUAN ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2517
Mailing Address - Country:US
Mailing Address - Phone:719-845-0001
Mailing Address - Fax:719-845-8882
Practice Address - Street 1:500 SAN JUAN ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2517
Practice Address - Country:US
Practice Address - Phone:719-845-0001
Practice Address - Fax:719-845-8882
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO507278Medicare ID - Type UnspecifiedINDIVIDUAL