Provider Demographics
NPI:1104667740
Name:CLARK, CAIIUS (LAC)
Entity type:Individual
Prefix:
First Name:CAIIUS
Middle Name:
Last Name:CLARK
Suffix:
Gender:X
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6317 BROAD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROYALTON
Mailing Address - State:VT
Mailing Address - Zip Code:05068-9774
Mailing Address - Country:US
Mailing Address - Phone:802-356-0171
Mailing Address - Fax:
Practice Address - Street 1:68 LYME RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1212
Practice Address - Country:US
Practice Address - Phone:802-356-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH356171100000X
VT091.0134095171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist