Provider Demographics
NPI:1912496282
Name:CLARK, ERIC B JR (DC,CCMA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:CLARK
Suffix:JR
Gender:F
Credentials:DC,CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10725 ABERCORN ST APT 143
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1441
Mailing Address - Country:US
Mailing Address - Phone:912-996-0961
Mailing Address - Fax:
Practice Address - Street 1:10725 ABERCORN ST APT 143
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1441
Practice Address - Country:US
Practice Address - Phone:912-996-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009974111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIR009974OtherSTATE LICENSE