Provider Demographics
NPI:1720153026
Name:CLARK, DALE THOMAS (DC)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:THOMAS
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 1:8907 WARNER AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5099
Mailing Address - Country:US
Mailing Address - Phone:714-842-6122
Mailing Address - Fax:714-375-2591
Practice Address - Street 1:8907 WARNER AVE STE 160
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5099
Practice Address - Country:US
Practice Address - Phone:714-842-6122
Practice Address - Fax:714-375-2591
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13913111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17638Medicare UPIN
CADC13913Medicare ID - Type Unspecified