Provider Demographics
NPI:1558156182
Name:PRO-ACTIVE WELLNESS CENTER, NATHAN CLARK CHIROPRACTIC, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PRO-ACTIVE WELLNESS CENTER, NATHAN CLARK CHIROPRACTIC, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-477-7845
Mailing Address - Street 1:2310 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3114
Mailing Address - Country:US
Mailing Address - Phone:310-372-2063
Mailing Address - Fax:
Practice Address - Street 1:2310 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3114
Practice Address - Country:US
Practice Address - Phone:310-372-2063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO-ACTIVE WELLNESS CENTER, NATHAN CLARK CHIROPRACTIC, PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty