Provider Demographics
NPI:1316959786
Name:CLARK CHIROPRACTIC
Entity type:Organization
Organization Name:CLARK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:NED
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-692-1178
Mailing Address - Street 1:9100 SILVERDALE WAY NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8389
Mailing Address - Country:US
Mailing Address - Phone:360-692-1178
Mailing Address - Fax:
Practice Address - Street 1:9100 SILVERDALE WAY NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8389
Practice Address - Country:US
Practice Address - Phone:360-692-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1687111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5370CLOtherREG BS
WA54222Other1ST CHOICE
WA184303OtherL&I PR#
WA1687OtherLIC#
WA5370CLOtherREG BS