Provider Demographics
NPI:1386731677
Name:CLARK, JOHN GREGORY (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GREGORY
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4678 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0903
Mailing Address - Country:US
Mailing Address - Phone:559-226-3400
Mailing Address - Fax:559-226-3963
Practice Address - Street 1:7461 N 1ST ST
Practice Address - Street 2:STE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2850
Practice Address - Country:US
Practice Address - Phone:559-226-3400
Practice Address - Fax:559-226-3963
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17061111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0170610Medicare UPIN