Provider Demographics
NPI:1316985278
Name:CLARK, JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
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 1:1448 ELLIS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08343-2816
Mailing Address - Country:US
Mailing Address - Phone:856-223-0194
Mailing Address - Fax:
Practice Address - Street 1:1300 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:NJ
Practice Address - Zip Code:08029-1308
Practice Address - Country:US
Practice Address - Phone:856-939-8889
Practice Address - Fax:856-939-5057
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC03097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8013705Medicaid
NJ8013705Medicaid