Provider Demographics
NPI:1396784476
Name:CLARK, AMIE C (DC)
Entity type:Individual
Prefix:MISS
First Name:AMIE
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 PASCOE BLVD.
Mailing Address - Street 2:STE.106
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-843-1930
Mailing Address - Fax:866-530-9599
Practice Address - Street 1:351 PASCOE BLVD.
Practice Address - Street 2:SUITE. 106
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-843-1930
Practice Address - Fax:866-530-9599
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000477912OtherANTHEM
KY85003341Medicaid
KY85003341Medicaid