Provider Demographics
NPI:1316009756
Name:PORTER & CLARK CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:PORTER & CLARK CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-379-9200
Mailing Address - Street 1:29100 GATEWAY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2764
Mailing Address - Country:US
Mailing Address - Phone:734-379-9200
Mailing Address - Fax:734-379-9229
Practice Address - Street 1:29100 GATEWAY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-2764
Practice Address - Country:US
Practice Address - Phone:734-379-9200
Practice Address - Fax:734-379-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2009-04-01
Deactivation Date:2007-04-04
Deactivation Code:
Reactivation Date:2007-06-05
Provider Licenses
StateLicense IDTaxonomies
MITC005814111N00000X
MIJF008106111N00000X
MIMP004985111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H220980OtherBLUE CROSS
MI950H220980OtherBLUE CROSS