Provider Demographics
NPI:1811147325
Name:STARK, TIMOTHY W (DC DACBSP ICSSD CSCS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:STARK
Suffix:
Gender:M
Credentials:DC DACBSP ICSSD CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 13TH AVE E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3380
Mailing Address - Country:US
Mailing Address - Phone:701-492-0696
Mailing Address - Fax:701-492-0696
Practice Address - Street 1:715 13TH AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3380
Practice Address - Country:US
Practice Address - Phone:701-492-0696
Practice Address - Fax:701-492-0696
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND647111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician