Provider Demographics
NPI:1982811493
Name:CLARK, JOHN RICHARD II (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:CLARK
Suffix:II
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 1:614 NW DELAWARE AVE # A
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3226
Mailing Address - Country:US
Mailing Address - Phone:541-389-5849
Mailing Address - Fax:541-330-8366
Practice Address - Street 1:750 SYCAMORE AVE STE B
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-7912
Practice Address - Country:US
Practice Address - Phone:760-598-1021
Practice Address - Fax:760-598-5584
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 17275111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor