Provider Demographics
NPI:1912322694
Name:CLARK, CHRISTOPHER W (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOI-E P.O. BOX 20161
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJUENE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-449-0494
Mailing Address - Fax:
Practice Address - Street 1:G544 C STREET
Practice Address - Street 2:
Practice Address - City:CAMP LEJUENE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-449-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2062171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider