Provider Demographics
NPI:1306994637
Name:CLARK, DIANE MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4705 S CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4103
Mailing Address - Country:US
Mailing Address - Phone:386-763-2728
Mailing Address - Fax:
Practice Address - Street 1:4705 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4103
Practice Address - Country:US
Practice Address - Phone:386-763-2728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5971111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22574OtherBCBS
FLP00706874OtherRAILROAD MEDICARE
FL001509400Medicaid
FL22574OtherBCBS