Provider Demographics
NPI:1386787398
Name:CLARK, DALE EUGENE (DC)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:EUGENE
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:PO BOX 546
Mailing Address - Street 2:109 RAINIER AVE SO, STE C
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-0546
Mailing Address - Country:US
Mailing Address - Phone:360-832-6200
Mailing Address - Fax:
Practice Address - Street 1:109 RAINIER AVE SO STE C
Practice Address - Street 2:
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328-0546
Practice Address - Country:US
Practice Address - Phone:360-832-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2103109OtherDSHS
WA2103109OtherDSHS