1326254798 NPI number — CLARK CHIROPRACTIC CENTER, LLC

Table of content: (NPI 1326254798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326254798 NPI number — CLARK CHIROPRACTIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK CHIROPRACTIC CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHRISTOPHER R. CLARK, D.C.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326254798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
177 E HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYNESBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15370-1818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-852-1777
Provider Business Mailing Address Fax Number:
724-852-1777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 E HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15370-1818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-852-1777
Provider Business Practice Location Address Fax Number:
724-852-1777
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
SOLE MANAGER
Authorized Official Telephone Number:
724-852-1777

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC007628L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1666127 . This is a "OGANIZATION BCBS NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1010082300001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134175474 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1326254798 . This is a "NPI NUMBER - GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 041052XGY . This is a "MEDICARE MEMBER PROVIDER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 897504 . This is a "INDIVIDUAL BCBS NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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