Provider Demographics
NPI:1215465042
Name:CLARK, TANNER (DC)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 N 500 W
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6948
Mailing Address - Country:US
Mailing Address - Phone:801-292-9355
Mailing Address - Fax:801-296-8050
Practice Address - Street 1:458 N 500 W
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6948
Practice Address - Country:US
Practice Address - Phone:801-292-9355
Practice Address - Fax:801-296-8050
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10316520-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor