Provider Demographics
NPI:1952555211
Name:CLARK CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CLARK CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:432-337-5553
Mailing Address - Street 1:6301 EASTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5045
Mailing Address - Country:US
Mailing Address - Phone:432-337-5553
Mailing Address - Fax:432-337-6183
Practice Address - Street 1:6301 EASTRIDGE RD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5045
Practice Address - Country:US
Practice Address - Phone:432-337-5553
Practice Address - Fax:432-337-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8532111N00000X
TX7347111N00000X
TX2256111N00000X
TX5928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609998Medicare PIN
TX605746Medicare PIN
TX600186Medicare PIN
TX603914Medicare PIN