Provider Demographics
NPI:1285077503
Name:CLARK, ERIC M (LIC AC)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:DENNIS PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02639-5123
Mailing Address - Country:US
Mailing Address - Phone:508-246-7602
Mailing Address - Fax:
Practice Address - Street 1:47 MAIN ST
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-2424
Practice Address - Country:US
Practice Address - Phone:508-246-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist